I'm In Tears :(

[TxMimi 16]

Hello,

I was so encouraged and excited by the fact our insurance BCBS/tennessee was so open & easy to work with WLS patients. I had all m y 'clearance' work done, paper work sent in, and 5 years past BMI being over 40 THEN BAM! The year I had a band, I'd lost over 40 pounds, during THAT year my BMI dropped to be under 40.

The insurance requires that I ahve 5 consecutive years of a BMI over 40!

I am heart broken, yet, have peace, the Lord will work this out. I do have high choloestral and have had since 06' BUT no one has ever put me on medicatin for it, they all wanted me to 'try weight loss' first.

Please pray with me & for me as I am SO VERY DICSOURAGED right now.

[Meljp 36]

I am so sorry to hear your bad news. That is so sad. I would be sure to read the policy and maybe even get your lawyer to take a look at it. It's a shame you have to go through this. I will keep you in my thoughts and prayers...Blessings~Melanie:)

[Wheetsin 714]

Usually insurance companies will make exceptions for revision patients. For example, my policy "requires" a 6 month supervised diet. But even though my band has been out for more than 6 months, the requirement was waived.

Have you actually filed and been denied, or are you just reacting to the verbiage in your policy?

I know a lot of people who have had revisions from one procedure to another. The BMI requirement is usually waived. I actually don't know of a single case where a revision has been denied because the BMI requirement is not met. That certainly doesn't mean there aren't a lot of them out there... just that I personally haven't seen one.

[Pookeyism 1,143]

I was self-pay. We had a strict no-no on WLS in our policy...good luck!

And HUGGS! Keep your chin up! I know you iwll get alot of advice here, hopefully it will be able to help.

[Sassygirl06 962]

It will work out, have faith! everything happens for a reason, its hard to see it now, but in the end it will become clear. I will pray for you that wou will be able to get the surgery soon! Keep the faith! I'm sorry that this has happened.

[favoredone 590]

I would call and speak w/ someone if you haven't already... I will definitely say a prayer for you...

[TxMimi 16]

It was actually an RN from our ins company that called me. The Dr office had sent over 5 years weight loss from 2006-2010 where I had a BMI over 40. For 2011 my BMI dropped to 38. Now I am back up. The ins policy is pretty leanient and straight forward: 5 years BMI over 40 and an in network dr/hospital. Thats it.

It does not allow for any other illneses due to weight, for the BMI to be lower. (I have high cholesterol) all it states per the benefits RN with all the paper work / documentation in front of her, is a BMI over 40 for 5 years. I had it for 5 years, then dropped to 38 last year. My last weight was taken last year in July as I have had 2 foot surgeries after that, being in a wheelchair and casted until after Jan this year. So no weights taken after July!

The RN is going to re submitt it but is highly expecting a denial and was just trying to see if I had a weight for 2011 that would put me over 40BMI. Which I don't. She the RN had has the sleeve done and is an advocate for it! She sais she will do all she can to help me on her end, but in the end it is the medical directors decision.

Thanks for the encouragment everyone!

[Greg_P 9]

If you get a denial letter make sure you file a prompt appeal. Typically with most insurance compaines it's anywhere from 10-30 days window they will accept a appeal plea. Dont give up, fight them! Ask you doctor if he/she would be willing to write and sign a letter advocating their support of the VSG for you. I think you have a very soild case (if presented correctly) to win on a appeal.

[missmeow 156]

It was actually an RN from our ins company that called me. The Dr office had sent over 5 years weight loss from 2006-2010 where I had a BMI over 40. For 2011 my BMI dropped to 38. Now I am back up. The ins policy is pretty leanient and straight forward: 5 years BMI over 40 and an in network dr/hospital. Thats it.

It does not allow for any other illneses due to weight, for the BMI to be lower. (I have high cholesterol) all it states per the benefits RN with all the paper work / documentation in front of her, is a BMI over 40 for 5 years. I had it for 5 years, then dropped to 38 last year. My last weight was taken last year in July as I have had 2 foot surgeries after that, being in a wheelchair and casted until after Jan this year. So no weights taken after July!

The RN is going to re submitt it but is highly expecting a denial and was just trying to see if I had a weight for 2011 that would put me over 40BMI. Which I don't. She the RN had has the sleeve done and is an advocate for it! She sais she will do all she can to help me on her end, but in the end it is the medical directors decision.

Thanks for the encouragment everyone!

What about the 1-5 years before that? I would think if you can show a history of BMI over 40 with one year of attempted weight loss (and failed due to weight regain) you would be able to appeal it.

[piper 13]

It is just so unfortunate that they want things to get so far before they will help out. The insurance companies are not looking at the long haul, the complications coming down the pipe if they don't allow a courageous person to intervene with this surgery. I wonder if it is because obesity is just so endemic in this country that they only want to open the door a crack for fear that they will be absolutely inundated with folks who want the surgery. Whatever the reason, it's just not right. I hope you can obtain the coverage you need. Appeal.

[EnjoyingWhoIAmBecoming 16]

I am sorry to hear that. Stay positive. Dont give up. We are keeping you in our prayers...sending thoughts and huggs your way

[Wheetsin 714]

What's the timeline we're dealing with? When was your band put in, and when was it removed? Iif you haven't, I would chart that out in preparation for an appeal. On it, tag known, medically verifiable weights (e.g. any and all medical check-ups, not just PCP or bariatric surgeron). It's a good practice to submit a claim, and then start working on the denial - with things like this that can have ambiguous requirements, it's best to assume you're denied and be over-prepared, than be caught off guard.

If you need to appeal, it sometimes takes a loophole, a bit of creativity, etc. E.g. for my appeal I had to prove I'd followed a medically required diet. There really isn't one with the band, so how do I prove that? I also had to prove mechanical failure above and beyond xray and EGD showing a slip. That one was a bit harder to prove. So start looking at the different avesnues you might be able to take. What's the exact verbiage of the requirement in your plan? E.g. does it say something like "BMI over 40 for the last 5 years" or does it say something closer to 'BMI over 40 for 5+ years".

I've worked for, and consulted with, insurance companies for years. I've gotten my own denials reversed, and have helped a lot of other people get theirs reversed as well. It is doable as long as you meet the criteria, and can prove that you meet it. Just don't get super discouraged. I honestly see revision patients all the time with "# of years over X BMI" requirements who have that requirement waived due to previous bariatric procedure. Although it sometimes will depend on why the previous procedure failed. If you don't mind sharing, why was your band removed? If for a mechanical failure, that should help.

[Wheetsin 714]

piper, I quoted your post but this is much for general info than a response directly toward you.

Insurance companies have pretty strict requirements for things like this because they are for-profit business that need to make money. A lot of people think that 6 month supervised diets are to prove you can follow a diet -- I don't think that's the case. I think they're functionally waiting periods during which they can get something for their expense - ROI. They're trying to make the risk pool be profitable. Same as plan-enforced waiting periods (periods of time during which certain benefits will be unavailable).

BMI requirements probably mean something like - under that BMI, your medical compllications will likely be cheaper to treat than to resolve. People want insurance companies to be altruistic entities that do things because it's "right" or "fair." I can't tell you how many people I've seen wanting to appeal denials for things excluded from their plan. Insurance companies (like almost every company out there) aren't in business to help, they're in business to be profitable.

The good news is that they write their requirements, they make them accessible (though perhaps not easily interpretable), and for the most part they're pretty good at following what they set forth. There is subjectivity built in, but that's true from the very beginning, long before you even become a member. A lot of the defecit I see is in communication between the provider and the insurance company. I'd love to see surgery clinics hiring former insurance company employees, and actually provide training on 1) deciphering insurance, 2) understanding the requirements, 3) providing the right info at the right time. Then patients wouldn't have to advocate for themselves so much. I'd love for insurane companies to have more transparency in their requirements, and more resources to actually help people understand the requirements. It took me no fewer than 11 phone calls just to find out how my insurance company defined "mechanical failure". There's a world of ambiguity in that single requirement alone. I was on the phone more or less demanding that they tell me "What documentation will you accept as proof of a mechanical failure?" -- I'm persistent, and I still never got a really great answer. And the answer changed based on who I talked to, even though the "in writing" requirement was the same. (I handled my own denial for my sleeve because I knew way more than the insurance coordinator did - she essentially became my fax machine.)

Too few people understand how insurance works - generically, as well as with their own policies. And that means they have to sort of blindly trust the people who are hired for $8 an hour to mass file claims. Unfortunately doing it a lot doesn't really give you the experience to do it well.

HTH clears up some of the confusion.

It is just so unfortunate that they want things to get so far before they will help out. The insurance companies are not looking at the long haul, the complications coming down the pipe if they don't allow a courageous person to intervene with this surgery. I wonder if it is because obesity is just so endemic in this country that they only want to open the door a crack for fear that they will be absolutely inundated with folks who want the surgery. Whatever the reason, it's just not right. I hope you can obtain the coverage you need. Appeal.

[KatieOkieDokie 171]

I am sorry to hear this! I was actually given advice from a guy that works at my local Social Security Office (in there to discuss matters NOT related to well even me). He told me to never give up the fight, and if I get denied to keep appealing appealing appealing! He said each time you appeal it goes to new fresh eyes, and eventually someone will see something others didn't, and OK it! He said the more they deny, the hard and stronger I fight. It was really encouraging! I advise it! lol

[vsggal 1]

Hello' date='

I was so encouraged and excited by the fact our insurance BCBS/tennessee was so open & easy to work with WLS patients. I had all m y 'clearance' work done, paper work sent in, and 5 years past BMI being over 40 THEN BAM! The year I had a band, I'd lost over 40 pounds, during THAT year my BMI dropped to be under 40.

The insurance requires that I ahve 5 consecutive years of a BMI over 40!

I am heart broken, yet, have peace, the Lord will work this out. I do have high choloestral and have had since 06' BUT no one has ever put me on medicatin for it, they all wanted me to 'try weight loss' first.

Please pray with me & for me as I am SO VERY DICSOURAGED right now.[/quote']

Did you finally get an approval???