SarahMarie83

Hello, I work for BCBS here in IL and have some advice for you. About the pre-existing clause - if you had insurance coverage prior to your current plan then you may be able to get that waived. Call your insurance carrier and find out if that's a possibility for you. Also find out if your BMI has to be 40+ for the entire 3 years or just at time of surgery. Ask if you can look up the Medical Policy used to deny you online or if they will provide you something in writing so you and your doctor have a finite list of exactly what you need. If all else fails, there's always the appeals process and they are generally reviewed outside of the strict policy based on true medical necessity. Don't give up hope just yet! Call your insurance company and find someone who is willing to take the time to help you and get the answers that you need. If you can afford it, by all means go with self pay....but very few of us are that position so I would recommend doing all you can to get it covered under your insurance. Hope this helps!

Hello, I work for an insurance company(BCBS IL actually) and see these quite often. I would recommend calling you insurance company and asking exactly what they're looking for. Also, if you go to the Provider section of their website you can probably find the Medical Policy that they're referencing and you can provide that to your surgeon to let them know in detail what is required. If they still deny your surgery after they get the info requested then ask how to appeal the decision. The reason these surgeries get denied so often is because the insurance company has a strict policy that they're adhering to but if it's truly medically necessary for your health and if you stick with it, you can most likely get that approval. The letter you posted doesn't say that you DIDN'T meet any requirements, just that something was missing so I would say your chances are good. As for the two reasons listed, it looks like the first part that says "Not a medical necessity' is just the standard verbage meaning that all requirements not met. It is the second paragraph that gives you the info you need on what was missing. Good luck to you and if you need any help with insurance lingo, let me know and I'll help you decipher things. Sarah