round 1

Thinjen · September 10, 2005

Well, blue cross, blue shield of Tennessee has denied me. Now, I have to start the appeal process. So, I may not be on here for a while, because this appeal will become my full time job. The nerve of them!!

NJChick · September 10, 2005

Sorry Jen, hope to see you soon. GOOD LUCK!!

bbblampwork · September 11, 2005

Please keep us posted. If I get denied I would love to know how you are getting approved. Good luck. I hope you knock em out in round 2

the best me · September 11, 2005

Hey Jen, why did they deny you? That will tell you alot about what to do from here. You prolly know this but it's good help to others...

anyhow, bummer. Keep us posted.

banded_for_life · September 11, 2005

Good Luck and keep fighting!

Jammin & Losin · September 11, 2005

Jen come here to vent to us if nothing else! I hope you will get aproved soon! Good luck!

Thinjen · September 11, 2005

They said that it was a predetermination for medical necessity for gastric bypass. Guess what, I couldn't agree with them more that I don't need gastric bypass. That's not what this was about...bunch of dummies!

The letter said that the requested service is not "medically necessary." Gastric bypass is not medically necessary or requested for that matter. I'm going to find out what is going on tomorrow when they open. Thanks for the support guys. I'm going to need it.

Thinjen · September 21, 2005

Update. Ins wants 6 months doctor supervised diet. Well, I've been seeing the doc for various things the last three months...so only 3 more to go. She's been weighing me...discussing my diet and exercise etc. Hope that works. Looks like I'll be banded after the first of the year. It's ok. My family doesn't know that I'm having it done. My DH does...but that's it. So, my family will just assume that I'm losing my January weight (my yearly resolution that has gotten me up to 270 pounds)...again. What they don't know is that I won't be regaining it this time. I'm gonna trick them..I'm gonna trick them...nannie nannie boo boo.

banded_for_life · September 21, 2005

Jen that is great!!! You hang in there and the new year will be here before you know it!

sarcar · October 8, 2005

I was originally and several times denied because "not medically necessary". This is a catch-all phrase. The first time is because they couldn't find all the previous diets in the upteen hundred pages sent to them. The next time was because they wanted me to do a 3-month diet that I would be on after the surgery. That was documented and sent to the insurance company and they denied "not medically necessary" because in Texas a PA has the same signature rights as a MD. They won't accept a PA's signature and the doctor's office had to resend with the nutritionist, PA and MD signatures. They said they would approve once they got the letter with this signature. Nope - not medically necessary. The doctor appealed and yesterday after 30-long days waiting on the appeal it finally got approved. All of the reasons denied said "not medically necessary" but I have found out that if you push the right people at the insurance, you will get the true reason it was denied. Many times it is just that they don't have all the information. Other times, they want you to do more dieting and proving. And then they also want to weed out those that think this is a quick fix and aren't willing to push hard for this. If you give up - they win. I've heard of people taking a year or more to get approved while some got approved the first time. I had to jump through a lot of hoops, but after six months, mine got approved. Keep up the chin and don't let them get to you. It is a VERY emotional ride.

Thinjen · February 10, 2006

bump, bump, bump. Well, finished my 6 month diet. Submitted all of my stuff. Guess what...."not medically necessary." What? I am in bed 14 hours a day on a heating pad and in the recliner for 6 hours a day on a heating pad...and not medically necessary? I called my husband's human resource department and they agree with the insurance company's strict guidelines. I do too. Hey Mr. Smartee, you have none of my medical data, history, test results and you agree with their guidelines. See, here's the deal. I've met all of their stinking guidelines. So, I came on here and found posts from Alexander and GeezerSue. Between their two posts (thanks, gals) I have formulated one heck of an appeal letter. We'll see if it works. After this, I'm going to the insurance commission. Then, I'll get a lawyer. See, I am a nurse, but currently am not working. I'm also a law student. I have nothing better to do than to fight this. Stay tuned... and thanks for all of the support. I love you guys.

Jen

DeLarla · February 10, 2006

OMG, you went through all that for nothing? I'm on your side. Appeal and kick their skinny butts!

Thinjen · March 6, 2006

bump. bump. bump. Talked to blue cross today via video/telephone and was told that "It has 30 days to go before the committee, after that we have 5 days to send you our response." It was hard to have a conversation, because they were so muffled. Please see below for a picture from our meeting.