Hi all,

I am so upset. I just found out today that I was denied the surgery. They said it was not medically necessary. I have a BMI of 39. If I'm not fat enough, that is truly pathetic. My surgeon's office is appealing the denial. Is that usually the course of action. I was thinking about writing a letter in addition to the surgeon's appeal. What does the surgeon's office do as far as appeals go? I need help. Please let me know what you all think I should do. I was scheduled for July 11th and now who knows when I'll get it done.

Emily

My insurance covers the procedure. As a matter of fact, most insurance companies cover WLS now however, they make the process extremely difficult. Insurance companies want to see a BMI of 40+ (I don't have that) or a BMI of 35+ with two co-morbitities. (I have that) The problem... If the Insurance company does not find it to be "medically necessary" they could deny you. Basically, that means if we don't have life-threatening co-morbitities, they won't cover the procedure. Obesity is a disease and as we all know a disease that could potentially kill us. That alone should be the deciding factor in determining medical necessity. It's a scary thought. I know my insurance company and probably most insurance companies would approve with a 40+ BMI as long as the patient has been at that BMI for atleast five years.

Then again, I have heard of people getting denied with a BMI of 44, 45, and 46. So who knows. I honestly think that insurance companies deny patients hoping that the patient would back down after the first denial.

Are the tests that you're taking Pre-op? Are you in the process of pre-authorization? Who is your insurance company?

em

Hi Em,

Yes my tests are pre-op...the doc gets all the facts, then sends them to my insurance at once so they can get the whole pic. my bmi is 41....with no co-morbidities. Doc says I am perfect candidate (esp without the co-morbities)! I called insurance and they were like yeah we cover it. My doc calls the insurance and my sis told me that the woman in his office never gets denied...lol she must be something huh? my insurance is New Jersey Carpenters Health Fund. It is a private insurance thru hubby's work. but hey they cover Lasik eye surgery so i am keeping my fingers crossed. I even got the approval letter from my general practicioner to get banded. hmmm ...getting nervous now.

That's a good sign. However, I thought after my letter and the letter from my PCP it was going to be a slam dunk. Boy was I wrong. I had every health document plus and I was still denied.

You approval looks good. If the insurance company is already paying for your pre-op then I would assume they will pay for the procedure.

Em1125

Did you go through all your pre-op visits? If you did, did the insurance company cover them then not approve your surgery? I have all my appts set up for pre-op testing. I wonder if they will approve them?

I hate insurance companies..we pay so much for insurance as it is.. it's crazy.

I have not done pre-op as of yet. My insurance has not approved the surgery yet. My surgeon is requesting (after approval )from the ins. comp that I receive an upper GI serious, EKG, and blood work. I can't do this unitl I know the reality of when the surgery will be perfomred.

I will tell you this. I AM HAVING THE SURGERY IN AUGUST NO MATTER WHAT. THAT HAS ALREADY BEEN DECIDED. Whether I'm approved or not. I can't wait another day as it is. I spoke with my suregeon's assistant and she promised that she would schedule/squeeze me in for mid-august should I have to self-pay. It's a big nut to crack but, I'm done with the battling. I will not wait a year of fighting with them. I'm in the position to self-pay however, I could have found better things to do with $23,000. Just a thought... I may hire an attorney to fight this battle to see if I could get my money back. I've heard of these things happening.

I honestly feel that the insurance company is completely wrong and unethical. Hey, maybe I'll feel differently about them should my appeal get overturned.

My first pre-op test in on Aug 3rd..I have to go for an upper GI test too. I have bad GERD, he knows my gallbladder is gone.

I don't have any money to self pay. I wish :eek: otherwise I would. Are there loans you can get out to help with stuff like this?

Thanks!

There are medical loans but I'm not sure how to go about it. If you have an equity loan you could borrow from there. Not to mention--it's a right off at the end of the year.

I would also ask for help on this LBT website. There are so many people here that are educated on these issues.

sorry for the mispelling. It's a write-off at the end of the year.

Hmmm...I don't know how they can deny you without even have had your pre-ops yet....they don't know your medical condition until you have that done! That is why I don't know if i am approved by insurance yet because the doc is waiting for the last test result (apnea) and then gonna throw all the tests at insurance at once.....but along the way, the hospital submitted my ekg, apt, etc....and they are going to pay it as soon as the doc submits a letter of medical necessity to them. Insurance already paid for my blood work, they already paid for my psych eval (which that stunned me!!) the only thing they may not pay is for the nutritionist, and that I will submit once its all said and done...but I have been talking to my insurance regularly and they are telling me everything is covered as long as the doc deems it necessary. My friend had gastric done and her insurance denied the nutritionist and the psych eval...she just kept submitting it telling them it WAS necessary for the procedure that they approved of!!! She said after the 3rd time, they paid it! LOL

Oh and the doc called me yesterday to discuss my apnea (which makes me think i dont' have it if he is gonna tell me over the phone) so then, I will call the surgeon and schedule the banding...I have to go to banding boot camp first 2 weeks prior and then I am set...(keeping fingers crossed that insurance is gonna come thru too...lol)

I have had blood work and a cardiac workup due to other issues i have had in the last month. We submitted that to insurance and they covered it. But that's not considered pre-op. I will need a recent EKG and blood work done. That won't be a problem getting that done and paid for. But for surgical reasons, the testing cannot be older than a month old. That's why I'm waiting a little bit. I am also having a sleep apnea study done but I'm waiting for insurance approval to have that covered. This is just possibly more amunition for me to get approved. A GI series will be done once I have been approved for the surgery.

Good luck to you.

Another thing Bettina, they have denied me based on my past history of obesity. I have had a BMI of 39 for less than 2 months. Before that it was less. They are basing thier decision on my 39 BMI with no life-threatening co-morbitities and not being overweight for at least five years. I of course appealed that because that's a bunch of crap. Like I said before, Obesity is major and causes more life threatning co-morbid diseases. I may not have Diabetes or high blood pressure, but the odds are very much against me if I don't do something about my weight.

According to my insurance booklet, I do meet the criterion for WLS. I think they feel I may just back down from this eventually. They are highly mistaken. I feel very strongly about this issue.

I have to say, if you look around the LBT forum you will see that many of the people here are self pay. What does that tell us about insurance companies?? It's scary.

With all that said, I just wish you all the luck. I know your nervous but hopefully your insurance company is a lot easier than mine.

Keep me informed.

I am sorry if I stirred things up. I just meant that i can't believe they would deny you without your pre-op testing done yet. I too have not been this heavy for more than two months also.

Good luck!

Not at all. Thanks Bettina. Let me know when your insurance company gets back to you. I'll keep you informed.

I went through the first barrium swallow then submitted to Insurance..they came back with thier list of demands (psych eval, 6 month monitored program and meet once with a nutritionist). Ok, first denial, but can deal with it. Got everything done, submitted again, denied again. Claimed they didnt have enough info from my pcp from the 6 month diet..umm..ok? So send in more infoe and submit again, denied. Said there is still not enough documentation to support approval. In the mean time I have mistakenly been told by 2 people I was approved and to go ahead and schedual my pre-ops. Told them I wanted it in writing, letters never cames, called 4 times, finally got who would become my case manager who told me that I wasnt approved, I was just fat enough to be considered...ummm..excuse me, but no shit! I was like, well, what more info can I give you people?? Its not like I am giving them my medical records, my pcp's office is submitting them. Then the hours of conference calls started..back and fourth until it finally was given to a nurse at the insurance company who I guess puts in her two cents...well, she stamed her yes on it and then it went on until i finally got my letter on Friday.

WTF? I went to the seminar last August and surgery scheduled for August 9th..a full year...If I was in the position to self pay it may have been an option, but gotta tell you...it was almost an obsession, I couldnt give up after all that.

To add to the complications..I have Guardian Health insurance who employs Alliance to decide who gets pre certifications and both companies are owned by United Health Care...sooooo.....I had to go back and forth with three diferent companies who obviously dont communicate very well.

Thats my story and Im sticking to it... :faint:

Angie

August 9th, Reston, VA

wow what an ordeal. I got my letter today. I has a long disclaimer in it , but I called to clarify and I guess that is about as good as it gets for acceptance letters from BCBS. I know what you mean about it becoming an obsession. It seems I have been working on this day and night all summer!! I don't know how you waited a whole year. I was about to go stir-crazy before I got the call from BCBS and I still may before I get banded.