I found out why I was denied, now what??

[dillon1205 0]

I filed with my insurace bcbs nc last monday and was denied on wednesday. When my surgeon got the denial letter it stated my denial was b/c my phsycologist letter was not detailed enough and that was the only reason for the denial. My surgeon said that they will now resubmit the info with a new letter does this now mean that I will be approved b/c I have made the needed changes or can they come up with a new reason for denial even though there were no other reasons listed??

[Lana24 10]

I filed with my insurace bcbs nc last monday and was denied on wednesday. When my surgeon got the denial letter it stated my denial was b/c my phsycologist letter was not detailed enough and that was the only reason for the denial. My surgeon said that they will now resubmit the info with a new letter does this now mean that I will be approved b/c I have made the needed changes or can they come up with a new reason for denial even though there were no other reasons listed??

Hi Dillon1205,

If it makes you feel any better I was denied 5 times before I finally got approved...it just means they will try again...make the necessary changes and simply try again. Don't "read" anything into it...if they deny you again...Find out why and re-appy!:cursing:

Best of luck, Lana

[HeatherO 7]

Just keep responding and giving it a shot. Many people get an initial denial and later everything goes through as long as they are diligent.

[Mrsace13 0]

Hi Dillon1205,

If it makes you feel any better I was denied 5 times before I finally got approved...it just means they will try again...make the necessary changes and simply try again. Don't "read" anything into it...if they deny you again...Find out why and re-appy!:wink_smile:

Best of luck, Lana

Why were you denied 5 times? Were they all paper work problems? I just found out today I was declined and I will find out tomorrow why but the lady from the insurance said my BMI was 39.4 and I didn't have enough medical problems. Have you ever had any problems like that? And can I appeal as many times as I need to? I can not give up on this.

Edited December 9, 2008 by Mrsace13
spelling error

[Lana24 10]

Why were you denied 5 times? Were they all paper work problems? I just found out today I was declined and I will find out tomorrow why but the lady from the insurance said my BMI was 39.4 and I didn't have enough medical problems. Have you ever had any problems like that? And can I appeal as many times as I need to? I can not give up on this.

Hi Theresa,

I was denied because I was neither fat enough nor sick enough. I was told to either get sick or gain 13 pounds so I could have the surgery! LOL So in my attempt to meet my insurance companies guideline < bmi of 40 or bmi of less than 40 with one co-morbidity> my blood pressure became unmanageable and thats how I was approved.

But yes it took 5 times, keep at it. Read your insurance companies guidlines and go from there. I hope this helps.

Lana

[Band_Groupie 3]

Read your insurance companies guidlines and go from there.

Ditto- get a copy (online usually-call your co.) and follow their guidelines. Every BCBS is different (even within the state of PA there are different BCBS policies). When they say "comorbidity" they usually just give a few examples and this is the vague part. I found out that usually that means you need at least one (some BCBS require more) of the "biggies" which are heart, blood pressure, cholesterol, diabetes and sleep apnea (all the other ones don't really count except to boost your case...ie. arthritis, asthma, GERD, etc.). Also these "biggies" need to have a Doctors diagnosis and treatment (ie. for high blood pressure you need to be on medication). Good luck!

[Lana24 10]

Ditto- get a copy (online usually-call your co.) and follow their guidelines. Every BCBS is different (even within the state of PA there are different BCBS policies). When they say "comorbidity" they usually just give a few examples and this is the vague part. I found out that usually that means you need at least one (some BCBS require more) of the "biggies" which are heart, blood pressure, cholesterol, diabetes and sleep apnea (all the other ones don't really count except to boost your case...ie. arthritis, asthma, GERD, etc.). Also these "biggies" need to have a Doctors diagnosis and treatment (ie. for high blood pressure you need to be on medication). Good luck!

Well said...

Lana

[Mrsace13 0]

Thanks SO much!! That really gives me hope. I have the guidelines and thought I had enough problems but I guess I need to prove them better to them. My BMI was so close and I know I'm a 40 now so maybe I need to go let them weigh me and send it in.

The dr has talked to the insurance dr today and I am waiting to hear back today if they approved me or do I need to appeal. I really think they are going to make me appeal this.

Thanks for the hope. I hope it doesn't take 5 times, lol, they will need to add stress issues then!! LOL.

[Mrsace13 0]

I filed with my insurace bcbs nc last monday and was denied on wednesday. When my surgeon got the denial letter it stated my denial was b/c my phsycologist letter was not detailed enough and that was the only reason for the denial. My surgeon said that they will now resubmit the info with a new letter does this now mean that I will be approved b/c I have made the needed changes or can they come up with a new reason for denial even though there were no other reasons listed??

Do you have an update yet??

[afw 0]

I also have BCBSNC, and I was approved in three days, as was my husband. We both had BMI's just over 40 (mine was 42, his was 41) and zero comorbities. BCBSNC is not one of those policies that search and search for some reason to deny you - if you give them the paperwork they want, and you meet their published guidelines, you should get approval. My bet is that the problem was exactly as stated, and when your psych provides a better letter, you will get approved. Count yourself lucky - from all I've read, we are about in the best position of anybody from an insurance coverage standpoint. Besides my surgeon's $500 program fee, I've paid one $20 copay at my first surgeon visit, and a $20 copay for each fill, and that's IT.

[dillon1205 0]

UPDATE****

My surgeon's office resubmitted the all the info Monday of this week. I have called the insurance company everyday this week and today I was told that their DR called my surgeon for a peer to peer yesterday and have gotten no response yet. My surgeon's office is moving into a new building TODAY (of course, another hoop to jump through) and he will not be avaliable until after 3pm today. I just really hope it all works out. Does anyone know about these peer to peers and if its a good thing or what? Keeping my fingers crossed. I want this surgery by the end of the year. I have a $5400 deductible that starts over jan 1. aaahhhh

Edited December 11, 2008 by dillon1205

[Mrsace13 0]

UPDATE****

My surgeon's office resubmitted the all the info Monday of this week. I have called the insurance company everyday this week and today I was told that their DR called my surgeon for a peer to peer yesterday and have gotten no response yet. My surgeon's office is moving into a new building TODAY (of course, another hoop to jump through) and he will not be avaliable until after 3pm today. I just really hope it all works out. Does anyone know about these peer to peers and if its a good thing or what? Keeping my fingers crossed. I want this surgery by the end of the year. I have a $5400 deductible that starts over jan 1. aaahhhh

YOU SOUND LIKE ME!!!! We are not alone!! I call everyday too. That is what they did today, a peer to peer and sorry, for me anyway, they still said to appeal. I didn't know what my dr could tell their (insurance) dr that wasn't already in the paperwork. So, I guess I will let the dr appeal it too, but it is NOW time for me to speak as well.

I'm getting ready to appeal and WIN!!!!

[Lana24 10]

LOl, Theresa

I really think the process it what my blood pressure high in the first place!

[dillon1205 0]

New Update***

Called insurance today and was told that my psychiatrist now needs to do the peer to peer with the insurance company's dr. I am just so confused. Why all these peer to peers? Are they jus making sure I can go through it? I was diagnosis with bipolar earlier this year and I am hoping that is not what is holding me up but I am sure it is........ Waiting stinks......

[Lana24 10]

update? What's happening...Dillon?