So I Got Denied Today

[Dianaw 2]

Mine was initially denied also. We appealed it and about 6 weeks later they approved it. Had my surgery on November 5th. Hang in there!

[cbd 78]

I was initially denied because they said I didn't submit the needed documentations for co morbidies. I resubmitted after seeing my primary and getting new labs done. I called to check on the resubmission and the insurance person told me that they had received it and didn't see any new info so sent out another denial letter. I nicely started to ask her if she saw then latest office note and new labs....she started looking and behold...she found the information...emailed the medical director and approved it within hours. i don't thing they even read it. Moral....keep calling and be persistant. Good luck. My sleeve date is January 10th.

[DreamsOfSkinny 53]

I was initially denied because they said I didn't submit the needed documentations for co morbidies. I resubmitted after seeing my primary and getting new labs done. I called to check on the resubmission and the insurance person told me that they had received it and didn't see any new info so sent out another denial letter. I nicely started to ask her if she saw then latest office note and new labs....she started looking and behold...she found the information...emailed the medical director and approved it within hours. i don't thing they even read it. Moral....keep calling and be persistant. Good luck. My sleeve date is January 10th.

Ty!! Yes, my Dr. Sent a follow-up note to insurance and they only say now that they never received it when my contact from work is now on my case... She said that with my co-morbidity that it should be approved without 5 yrs medical history of weight. So we'll see... Hoping to see what the ins. Response is by Friday. My contact is also getting them to answer why the ins. Has my current BMI wrong...

[my3kids4life 22]

Whooaa!!! I'm reading everyones replies now I'm a bit concern. I recently inquired with my employer & insurance company BCBS Florida was the WLS requirements changing for 2013. I was shown how to access the new contract my employer has agreed to. It shows a guarantee to approval with a BMI of 40 over for 5yrs (this is not me) or BMI 35 with one comorbity (my BMI 38 I have several comorbities) but IDK now after reading the stories on this forum. I have been on my VSG journey since April of this year. I pray I can get approval next year if not I will be Mexico bound.

[DreamsOfSkinny 53]

Whooaa!!! I'm reading everyones replies now I'm a bit concern. I recently inquired with my employer & insurance company BCBS Florida was the WLS requirements changing for 2013. I was shown how to access the new contract my employer has agreed to. It shows a guarantee to approval with a BMI of 40 over for 5yrs (this is not me) or BMI 35 with one comorbity (my BMI 38 I have several comorbities) but IDK now after reading the stories on this forum. I have been on my VSG journey since April of this year. I pray I can get approval next year if not I will be Mexico bound.

Everyone is VERY different.... I've found a lot has to do with the insurnance company. My Dr. said if I was with BCBS or Aetna that I would have been approved with first submission. The case manager now - through my employer - who is helping me correct clerical issues on UHC's side and other paperwork they overlooked told me to keep working on my appeal but that I probably won't need it. That was GREAT to hear today!!! Something positive in over a month! I started my journey Oct. 15th --- I think. I'm hoping to get surgery in December. If I can get approved by next week I think they can still squeeze me in. Now I need to lose 15 lbs!

[sarahec 18]

This is so frustrating I know..my surgeons office said they would be able to send to bc/bs electronically and we would have an answer with 4 days. Went to their office today to give the final paperwork to submit and the office staff tells me to get ready to be denied. In 2010 I lost 20lbs with the help of Adipex and that knocked my bmi down to 38 and I have no co-morbidities. As soon as I went off the adipex..SURPRISE I gained every bit of it back plus 15 and have held that ever since. That was 2 yrs ago. It will happen I am just gonna have to fight. My work just required that I use all my vacation time by the end of the year. I was hoping to use that time for recovery.

[my3kids4life 22]

This is so frustrating I know..my surgeons office said they would be able to send to bc/bs electronically and we would have an answer with 4 days. Went to their office today to give the final paperwork to submit and the office staff tells me to get ready to be denied. In 2010 I lost 20lbs with the help of Adipex and that knocked my bmi down to 38 and I have no co-morbidities. As soon as I went off the adipex..SURPRISE I gained every bit of it back plus 15 and have held that ever since. That was 2 yrs ago. It will happen I am just gonna have to fight. My work just required that I use all my vacation time by the end of the year. I was hoping to use that time for recovery.

You are so right Sarahec every insurance company, everyone, and every situation is different IT WILL HAPPEN. I have claim it. I was so excited after speaking with the insurance company especially when I was able to see it in black & white. I cant wait for January to get here so I can start the process again. I will fight back this time if I'm denied again. I'm not worry about because IT WILL HAPPEN in 2013 . Thanks, Good Luck

[sarahec 18]

Good luck to you too! Guess maybe they do all this to stress us out and make us quit. Can't say I haven't thought about quitting..but its gonna have to take a little more than this hang up!

[Heyher 581]

I keep hearing UHC likes to deny up to three times before approving this type surgery. As soon as I have my latest denial letter I am sending in the request for an expedited external review.

Thought I had done that, but UHC wanted to tell me no one more time.

Jerks. But now it is outof their hands. Thank god for the IRO.

[JustSayMoe 163]

If they are jerking you around go to the state dept of insurance. I made the threat to UHC after they screwed up twice. They promptly approved me after the threat.

[Heyher 581]

Depends on if it's fully insured or self funded. Fully insured reports to state regulation. Self funded follow federal law under ERISA.

[TXgrl210 0]

wow. I am currently waiting for an approval - I have BCBS of CA. not sure what to expect now. My BMI is 36.2 and I have sleep apnea and very borderline diabetic- I was given metformin to prevent the full blown diabetes. i have heard I have a really good Dr's office and they rarely seedenials. I am alway the negative thinker and believe I will be DENIED! but we shall see- I will follow up with the office Dec 5- that will be 2weeks.

[doreen70 268]

8 years ago, I fought my insurance company for approval for RNY ( so glad they denied me ). Jumped through every hoop. Begged every person in my husband's HR department for help. Gathered all of the doctor notes, weight loss clinic notes, prescription print outs. Did the sleep study, got the the CPAP. Saw a dietician, went to a psychiatrist. It was my full time job it seemed, and I was heartbroken to be told no-hours after I was told that it would be approved. It motivated me to at least try on my own, and I went from 377 to 230 through fad diets and exercise. I'm stuck at 275 now, and we decided that we would not try the insurance BS again. Paying out of pocket and my surgery is Dec 17th. Nervous as hell though, not sure what to expect.

[DreamsOfSkinny 53]

If they are jerking you around go to the state dept of insurance. I made the threat to UHC after they screwed up twice. They promptly approved me after the threat.

That would be my step after I'd get my appeal denied I think.... State commissioner. I need to find out if self funded or not.

[Heyher 581]

Do you have a description of benefits?

Or a summary plan description?

Summary plan description is self funded.