So I Got Denied Today

[Ballermom 803]

8 years ago' date=' 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.[/quote']

I like what you said about it being a full time job.

I have my second Nut visit in a week then pre op class and next day meet the Surgeon.

Some weeks has been tough just going through the process. This site is sooo helpful. i do feel for all who have been denied and hoping y'all get approved . I have not submitted mine yet. But i see its not just me thinking this is like a full time job. But worth it. We are on your side.

Good luck all!

[DreamsOfSkinny 53]

Do you have a description of benefits?

Or a summary plan description?

Summary plan description is self funded.

Self funded then.... Now let me look up ERISA ---I think you called it.

[HoosierGirl 780]

BCBS of Pennsylvania have denied me twice, said they don't have to offer external review because my plan is "grandfathered" and not subject to the healthcare reform laws. My BMI is high 35/low36 and I have hypertension and am on 2 meds ...although I completed EVERY step of the insurance requirements and met all requirements, I was denied becasuse my "hypertension is controlled with medication". My surgeon's office was stunned because they are on top of all the documentation requirements and have NEVER had a denial when all the requirements were met.

I'm currently working with Lindstrom Obesity Advocacy to see what my options are www.wlsappeals.com. They are VERY knowledgable. But I have been working on the denials and appeals for months.

So, I am deciding to take control and have been saving like a fiend. If I don't have a definative answer yes or no, I am on my way to MEXCIO! Then I will be in control of what I am getting for my money and when I get it.

[DreamsOfSkinny 53]

BCBS of Pennsylvania have denied me twice' date=' said they don't have to offer external review because my plan is "grandfathered" and not subject to the healthcare reform laws. My BMI is high 35/low36 and I have hypertension and am on 2 meds ...although I completed EVERY step of the insurance requirements and met all requirements, I was denied becasuse my "hypertension is controlled with medication". My surgeon's office was stunned because they are on top of all the documentation requirements and have NEVER had a denial when all the requirements were met.

I'm currently working with Lindstrom Obesity Advocacy to see what my options are www.wlsappeals.com. They are VERY knowledgable. But I have been working on the denials and appeals for months.

So, I am deciding to take control and have been saving like a fiend. If I don't have a definative answer yes or no, I am on my way to MEXCIO! Then I will be in control of what I am getting for my money and when I get it.

I was thinking about them if my employer's advocate can't help me by next week....

[ready4it 8]

I don't have much advice to offer, but I hope everything works out quickly for you. I know how frustrating it is to be denied and have to prove yourself. I mean really-who wants to have substantiate that they deserve a surgery they're suffering from x y z issues because they're overweight; don't we pay our insurance fees every month? I got all the way to pre-op the day before surgery and my dr.s office told me I was denied by insurance for too low of BMI and that I didn't have the "approved" co-morbs. Had I not asked, they probably would have allowed me to go to the hospital and I would have found out there! I know you can imagine all the preparation I'd put into it, including getting approved for time off from work, buying liquids, protien powders, etc. In my case a supposed "slam dunk" with BSNV was promised and the ball was dropped when they got my denial. That was in June, I've just been approved because my BMI is now 40 due to weight gain (co-morbs not required). It still seems like my dr.s office is not the most organized, but it's so late in the game, it would take way too much to change. If they don't get me scheduled by the end of Jan., I'll go to Mexico. Tired of jumping through everyones hoops-I want to get on with my life already.

I don't recall if you mentioned who your insurance is through, but perhaps this might be helpful to you:

Members in a Health Maintenance Organization

(***) and Exclusive Provider Organization

(EPO) Plan

The California Department of Managed Health Care

(DMHC) regulates all HMOs in California. If you are

an *** or EPO health plan enrollee, and you have

fi led a grievance and are dissatisfi ed with your ***

or EPO’s fi nal decision, you should contact the DMHC

*** Consumer Help Center at (888) 466-2219

or TTY (877) 688-9891 to register your complaint.

You also should request assistance through DMHC’s

website at www.dmhc.ca.gov. You may contact DMHC

if the matter is not resolved within 30 days from the

time your grievance was received by your health plan.

Contact them immediately if the matter is urgent.

If you have fi led a grievance and are dissatisfi ed

with your *** or EPO’s fi nal decision regarding your

eligibility for health benefi ts or limits of coverage under

the plan, you may contact CalPERS for assistance.

[somaiswhat 29]

I have BCBS and just said I had to be an informed patient, 18 or older. Didn't read anything about co morbities..

[sarahec 18]

My denial was from in 2010 my bmi was less than 40 with no comorbidities..so we resubmitted with pictures of myself in 2010 and a letter explaining I was on diet meds..have bc.bs..anyone else been denied like this?

[DreamsOfSkinny 53]

My denial was from in 2010 my bmi was less than 40 with no comorbidities..so we resubmitted with pictures of myself in 2010 and a letter explaining I was on diet meds..have bc.bs..anyone else been denied like this?

So after some help from advocacy group from work, I have a nurse case manager. The insurance corrected their BMI for me for 2012 but then said my BMI wasn't 40 for last 5 yrs. and they didn't even have the 5th year (2008). I re-faxed over the "correct" weights aka my highest for each year today to insurance and told them my weight fluctuated bc I was on medically supervised weight loss programs that obviously didn't work long-term, explained my Supplement Plan Document doesn't state I need BMI of 40+ for last 5 yrs. but a diagnosis of morbid obesity - which I have and sent letter today too- and then showed proof that National Institute of Health defines morbid obesity as 40 ORRRR 35+ 1 sever co-morbidity. I have Pseudotumor cerebri since 2008 and it's come back since I can't keep my weight down and it's directly related to obesity and also sent in documents of most other insurances an medical institutions saying Pseudotumor is a sever co-morbidity for having bariatric surgery and using bmi 35+ co-morbidity as morbid obese.....

We're hoping to hear from them next week to see what they say. If denied again I think I'm go to the obesity lawyer and file appeal. :-/ Issue is I need to have the surgery within the next 6 weeks!!! Otherwise I lose my insurance.

[DreamsOfSkinny 53]

Ohhh my BMI's were 38.1-39.8 for last 4 years. :-/

[stacybaby 0]

Is it as important that you have a BMi of 35-40 when you get it done in mexico.....I mean that you maintain a35-40 BMi for five years

[Heyher 581]

@Dreams

Why are they canceling your insurance if you don't get surgery?

@Stacy

Doctors in Mexico have different requirements for surgery. And insurance policies have different requirements here in the states.

This week I was told by one rep that WLS is not a covered benefit. Ummm yes it is.

Then I was told by a supervisor that external appeals are not allowed on my plan. Ummm yes they are. BUT I think my external review was finally sent off.

[DreamsOfSkinny 53]

@Dreams

Why are they canceling your insurance if you don't get surgery?

@Stacy

Doctors in Mexico have different requirements for surgery. And insurance policies have different requirements here in the states.

This week I was told by one rep that WLS is not a covered benefit. Ummm yes it is.

Then I was told by a supervisor that external appeals are not allowed on my plan. Ummm yes they are. BUT I think my external review was finally sent off.

A whole nother story lol! I won't be with the same company after about Jan. 15-20th.... ish..., So really needing this done quickly. The insurance got my 28 page of extra/new information to review from the peer to peer denial. They never even read the follow up letter from my surgeon so hoping by doing this it will be approved and we won't have to go to appeal step.

I had BMI of 38.1-40.6 for last 5 years but thanks for the info.

[DreamsOfSkinny 53]

So I'm on 1st level appeal now and should know an answer by 12/21! I was told different information and didn't even know what I faxed in would be an appeal... Here we go! UHC said there is a 2nd level and then external. I also requested a bariatric surgeon be on the appeals team (hoping this helps!!)