BCBS Denied

[MMDLynn 0]

I can't believe after all of this BCBS denied my claim, stating that the Dr.'s 12month monitored plan was insufficient and that I needed to provide 5 years of comorbidity.

My Insulin Resistance from long-term PCOS had led to the excess weight and is leading down the path to Type II Diabetes. I'm so upset right now I can't stop crying. I can't believe this is happening to me, and now my Doctor says I'll have to start all over with another physician because he's moving to Arizona to retire in September. Basically he tried, but I need to start over another full year of physician supervised weight loss diet & exercise plan.

I'm so hurt - I thought this was my chance to finally improve my health. I'm 325lbs. with a BMI of 53 and Insulin Resistent on Metformin 3 x's daily to control - what else do they need?

I feel like my world just came to an end!

[ReneBean 3]

I have one word for you: FIGHT

http://www.obesitylaw.com/surgery.php

[NJChick 3]

I'm so so sorry. I can really understand your frustration, gosh I'd be crying too. I have BCBS as well and I am so worried they will deny me too.

Rene is right, FIGHT IT!!!!

My neighbors had BCBS a few years ago and their DD needed her tonsils out in the worst way, this poor kid went thru hell every other month with sore throats, etc. They asked me if I would help them write a letter to BCBS to ask them to reconsider. We wrote the letter and wouldn't you know, they approved the opperation !!!!!

So don't give up, there is ALWAYS hope.

Hugs and kisses and if I can help in any way, please let me know.

[Alexandra 55]

Lynn, the time for tears is over. They've told you what they need...12 months of the infamous supervised weight loss, and proof of 5 years of morbid obesity (with comorbidities? That's a new one on me if your BMI has been over 40 during that time. But whatever...).

Do you have any doctors you were seeing five years ago who may have notes on your weight? My insurer had the same requirement, and I went to my OB/GYN who had copious notes on my weight through two pregnancies. That conclusively proved my condition had been in existence five years prior.

The 12-month weight loss thing is a hassle, but there's no reason at all that you should have to start again just because your doctor is moving. His notes can be provided to another doctor who can just pick up where your first doc left off. You are still on the supervised plan, just with a different doctor.

Don't let them bully you. You have your list of requirements and you can indeed fulfill them. You qualify medically, that's certain, so all you have to do is jump through their hoops and you're there.

Eileen, you do know that BCBS is very different from state to state, right? You won't have any problem with approval in NJ if you qualify medically for bariatric surgery. They have no barriers to approval as long as it's medically necessary.

[SherriWittler 1]

My insurance also won't pay for it. I am going to self pay route so I can just get it done.

[shirley rohr 0]

My insurance wouldn't pay either, and I wasn't going to die waiting. We refied our house so that I could have it done. My hubby is an angel for doing it. I had the surgery on 4/15/05 and I am down 106 pounds. It has slowed down now and I just had a second fill, so I am ready to move the numbers down to the Tummy Tuck area!!! I started at 351+, my scales quite at 350, and I love putting on my old clothes and they fall off. I have gone from seatbelt extender on the plane to pulling the belt a good 10 inches. I love my band!!!!! I would do it all again if I had to....

[the best me 6]

Don't let them bully you. You have your list of requirements and you can indeed fulfill them. You qualify medically, that's certain, so all you have to do is jump through their hoops and you're there.

Bump in the road, girl. Don't give up. FIGHT! I know it takes energy and perseverence but many a bandster has gotten one Denial letter, only to fight and have their approval. All that letter is to you is a request to give them whatever it says they want. So give it to 'em. Make sure you get a copy of your entire medical record before your doc ships off to retirementville. Visit that website. Do what Alex said. Do what Rene and NJChick said and FIGHT!!!

They told you what they need. Give it, and you will get your approval.

((((((((HUGS))))))))) Please don't be discouraged!!! Don't cry anymore!!! You can do this!!!!!

[lovecats85 2]

I have BCBS of TX and they cover NO WL surgery No matter what! I got financing thru advanced patient financing (google them). Don't be upset - I know it's expensive but I am willing to drive a less fancy car, eat out less, etc. to make up for it.

[shirley rohr 0]

I had to self pay for mine too. Thats one reason I went to Mexico. I had a great team and the hospital and nurses were great. I have had 2 fills there also. I think the expensive part is keeping myself dressed. My clothes are way to big!! You will be so happy when this is over. Its like starting a new life.

[NJChick 3]

Alex, yes, I realize its different from state to state and plan to plan. I just have this awful feeling that they will give me a hard time. I guess I'm just not gonna get my hopes up just incase. But !! if for some reason they give me a hard time, I'm just gonna have to do some joisey ass kickin lolol growl !!!!

Hugs

[abrightfuture 0]

Lynn, sorry to here about your struggle. Here is something for you to consider. First of all I agree with everyone FIGHT!!! Secondly get out your plan booklet. As a medical claims processor I recommend you get very familiar with your benefit plan. Read, read,read. If your plan does cover WLS then thats the first thing, then look at the requirements, have you complied atleast with the majority of the guidelines? Don't be discouraged that your doctor is leaving there are others. Get all your records, everything from everyone you can think of. My doctor also sent along all the information regarding the sucess of the lapband. Then if they still deny you, file an appeal. All benefit plans have an appeal board. Also if nothing happens there being a BCBS plan you can file an request with your state insurance commisioner.

Just remember there is always a way. Dont give up. Just having the coverage in your plan is something many dont. Youll have to put in some extra work but its all worth it in the end.

Good Luck, if theres anything else let me know

Micki

[Chicagoboy 0]

10k cash and I was on my way. BC/BS sucks I can say from my own expeience but I knew it would. I went into this planning on self pay only. Try to raise the money some way thru 401k loan, home loan, credit card or sell your car.

[piercedqt78 658]

I was denied 3 times and I cried each and every time. Then I picked myself up and appealed, appealed, appealed. I was on my way to an independant evaluation (an outside comapny) and a bright idea hit me, call the union that provides the insurance. I called my husbands employeer and the union and guess what? I was approved, without even appealing or having to go with the independant company. I was told that the independant company would most likely overturn the denial anyway. Don't give up until you have exausted ALL options. Sometimes there is a reason for the wait time, mine was so that I could fully wrap my head around the idea of surgery and I began eating like a bandster. It gave me time to give up pop and I started walking each day. I had surgery 7/28/05 and I am down 30 pounds. ~Mandy

[PRETTYPINKKITTY 0]

WRITE YOUR OWN LETTER TO THE INSUR COMPANY AND GET YOUR RECORDS FOR ALL THE DOCTORS YOU HAVE BEEN TO IN THE LAST 5 YEARS. IF YOU ARE OVERWEIGHT, THEY ALWAYS NOTE IT IN SOME REGARD. I ALWAYS HEAR, "IF YOU LOSE SOME WEIGHT, YOU WON'T HAVE THIS PROBLEM." A FRIEND OF MINE DID THIS WHEN SHE WAS DENIED, AND IT WORKED. I'M STILL WAITING FOR APPROVAL, BUT I WENT AHEAD AND INCLUDED THESE WITH MY INITIAL PACKET TO THE INSUR. BETTER HAVE TOO MUCH THAN NOT ENOUGH!

[shirley rohr 0]

I can't believe our insurance companies would rather pay for heart attacks, strokes, diabetes, and what ever else comes our way. I am so tired of premiums up the wazzu and they pay for drug rehab and alcohol rehab, but what about eating rehab???