Need help with an appeal

[Mrsace13 0]

I have B/C B/S OH and they have denied me because my BMI 39.4 and I do not have two (even though my policy does not say I need two) medical conditions.

They did the Peer to Peer and denied again. I wasn't sure how that works since the only thing they could talk about would be the paper work they already had when they denied me the first time.

Too much stress so I waited until after the holiday to start going 100% with this appeal again but I don't know what I can do. My dr office is sending me a package so I hope that helps me understand. My dr office said to keep calling my insurance, but what am I supposed to be saying or asking if I call daily???

My BMI is now 40 with the stress and of course the holidays just ending. I also round up saying I'm 5'4" when I'm really 5' 3.5" and the half does make a difference with BMI, lol. I told my dr office that today and she said we could do a new weigh in and send it but since I have not had a BMI of 40 or more for the last two years that we shouldn't go there, I don't understand that, it doesn't say in my policy that I have to have a BMI of 40 for two years but I know my dr office knows what they are doing.

I'm just feeling no hope at this time, I'm so depressed and stressed out. I was so excided thinking I would be banded by Jan and now I'm wondering if I'm ever going to win this. I know I wont give up but I just don't know what I should be doing, writing, saying when I call, I feel lost. I guess I don't have any of the medical conditions even though I have never been to a sleep study but my dr said not to do that right now so I don't know what to do.

Any help would be great!! One of you had emailed me your appeal letter and it was great but I guess I don't have medical conditions to add even though I am a 40 BMI now.

Thanks, I really need this. I have other issues and I cant even hardly walk due to my weight but that is not life threatening they said. I am in pain daily due to my weight, I need some off to even start working out.

[HMBradley1965 0]

I am in the same boat as you almost My BMI is 34.7 I have high blood pressure and type 2 diabetes. I am so afraid I will be denied since it's about 3 pound off for me to have the required 35 BMI with 2 co morbids. I also have BC/BS of Mass. I know how you feel because if I was 1 inch shorter I would have been over 35. So I am going to submit a personal letter with my application one other thing that I have been doing the last 2 years is talking to the Blue Care Connect program where nurses will call see how your meds are going etc. and with this program I have been talking to a dietition so I am hoping they take this into consideration also. I have had these weight issues since my early 20's losing and regaining so I am hoping I will be qualified. What if you write them a personal letter???

[Memere-9 0]

I have BC BS Federal. I had a BMI of 35 with 2 health conditions. I was approved no problem. I confess I had to gain 3 lbs before my weigh in. The health issues is what they really look at. It will save them money in the long run. i am now 5 weeks post op and very happy. I feel very bad for the woman who has been denied twice but you really need 2 medical conditions.

[Memere-9 0]

I hope you find a way around this problem but I think they really look at the medical conditions. Maybe you could get some help from your primary care doctor. I was a BMI of 35 with 2 health conditions. You can see my age as well which may have been a factor in getting approval I haveBC BS federal they approved me in 3 weeks I was shocked and thought I would have to fight it. I think my lap ban program director was helpful as well.

[Mrsace13 0]

Is there a place I can find a list of the conditions they are looking for? I really think I need to go to a sleep study even though my dr office said I didn't need to do that. If I have sleep apnea, the insurance needs to know that.

I just don't know if I have any conditions, I did the blood work they requested, would all of that been covered in that? I'm not to bright when it comes to these types of issues.

[HMBradley1965 0]

Are you going through a Center for weight management???? They should know what you need to qualify...I thought if you have a BMI 40 or over you do not need to have any health issues if you are 35 -40 you need to have 2

high blood pressure, Type 2 diabetes, sleep apnea and some others the clinic your going to should know that. I would be pretty sure they would have tested you for diabetes when your blood work was done. Has your doctor said your blood pressure was high????? There should be a list of health conditions on this web site.

Helena

[Mrsace13 0]

Are you going through a Center for weight management???? They should know what you need to qualify...I thought if you have a BMI 40 or over you do not need to have any health issues if you are 35 -40 you need to have 2

high blood pressure, Type 2 diabetes, sleep apnea and some others the clinic your going to should know that. I would be pretty sure they would have tested you for diabetes when your blood work was done. Has your doctor said your blood pressure was high????? There should be a list of health conditions on this web site.

Helena

When they submitted it to the insurance my BMI was 39.4 so they are now giving me a hard time since I guess I don't have life threatening issues that we are aware of. I guess I just have to fight it with the fact that my BMI is over 40 now, my Wii Fit said so!! LOL, well, not funny but the stress is making me gain too!!:frown:

[mroseharvey 0]

I was in the same boat as you. My BMI was 35 and the health issues I had was high cholesterol and arthritis...I was like you my feet hurt so bad I cried at times when I walked. Well, my insurance company denied me saying that it was not medically necessary. Well I was so upset I cried for an entire day. My husband saw how upset I was and he hated to see me in pain....just to walk. So we decided to go ahead and self pay, I had the surgery on 12/15/08. I am going to appeal and fight with my insurance we will see what happens. But I decided that I am not going to let an insurance company tell me that I am not sick enough.....I know the pain I feel in my legs and feet. With just 11 lbs that have come off my feet feel better. Good luck with your appeal.

[Memere-9 0]

Congrats on your surgery and the courage to self pay. i know I was so nervous waiting for the insurance co to approve me. I have high blood pressure, heart problems, high cholestoral and was taking meds for my stomach. The insurance co was paying for 5 meds every month. I am down already to just my high blood pressure med so that is just 2 they are already saving money. Again my age I think was a factor. I know I had the lap ban so I would not end up like my mother who spent the last 20 yrs of her life home bound and died at 71 of nothing but complications from her weight. I also wish I had been more understand then of how hard it was for her not to eat. I did not have the serious weight issues then. It has been 5 weeks for me and I have stopped loosing weight and am starting to get discouraged this site is really a help.thanks to all who post and share.

[Mrsace13 0]

My drs office is sending me an appeal package and I am starting my letter.

Anything that might have helped you in your letter, please advise me.

I have gained weight as you can see by my ticker. I'm sure it is the stress of this, the hoildays and I quit smoking. I am not trying to gain weight and I don't want the insurance to think I am.

[HMBradley1965 0]

I haven't been submitted to insurance but I have written a letter to be submitted I have a feeling I will be denied because I hace a 34.7 BMI but I am type 2 diabetic and high blood pressure from 34.7 to a 35 is about 2.5 pounds. The clinic I go to said they had to use my very first weigh in so that's what we did. In my letter I explained my life as being overweight. During the last year I have lost some weight and quit smoking last feb. I am a cleaner and I walk 8 hours a day and it's taking a toll on my knees and ankles but in no way am I lazy with the type of job I have. I do zumba tapes a couple times a week or walk on the tradmill. I have tried every diet imaginable my whole life and yes I lose but I also gain it back. Yes it is a pitty letter and I should be done all my testing by the beginning of Feb so I started the letter last week and when I need to add to it I do....Good Luck...I hope this works for you and I both....

Helena :biggrin:

[Memere-9 0]

I did gain 2 lbs for my weigh in but I was foing back and forth for months. I will say again that maybe your pca can help find other health issues that you have. I had more than 2 health issues but was so surprised that I was approved. Don't give up keep fighting hopefully they will approve you.

[Mrsace13 0]

Thank you to all that are here for me. I really feel like giving up, maybe this wasn't meant for me.

With the holiday stress and my grandmother going in the hosptial two days before Christmas I decided to wait until after the holidays to fight full force, I have been working on my appeal letter and wanted to get it out by tomorrow.

My grandmother passed away at 4 pm yesterday, even with knowing she is in a better place and out of pain, it is still so hard and watching my mother cry is hurting me so much. So again, hard to work on my letter again.

I feel like I'm fighting something I can't win. When they put my info in my BMI was 39.2 or .4 or something so they denied me. I guess I dont have have life threatening issues and of course that is a good thing. I really thought they would find something if needed. So now that I know my BMI is over 40 since I quit smoking, stress and the holidays, it hasn't been over 40 before so they don't want to try to use that. I feel stuck. So I am going to do my best with my appeal letter and if I get denied again, what more can I do?

Does anyone know, if I decide to not appeal after that, how long do I need to wait to start fresh and do another claim knowing I'm over 40 BMI now? I dont know if I'll have to do all those visits and $$$$$ again that I have done. This is so stressful!! I wish I could afford to be a self pay and just get done!!

Thanks again everyone, I just feel defeated!!

[HMBradley1965 0]

Teresa I am so sorry about you grandmother...

When the time is right to appeal you will know it.

Good Luck with everything and keep us up to date...

Helena

[Memere-9 0]

I am so sorry to hear about your grand mother. I hope your memories will be comforting to you. I am also sorry to hear about your differcult process with WLS. I hope you will find a way to work this out. I don't have any information for you but I will keep an eye out for your progress.