Insurance Denied-Anthem BCBS

[crodrigu73 13]

Today my application for the sleeve was denied because the hospital I am going to have surgery in is not a center of excellence. I live over 350 miles from one and I feel it would be incredible difficult on me and my family to travel that far for surgery and for follow-up. To add to this I will be having an infected hernia mesh removed and replaced at the same time so I really would like to be close to my doctor for my recovery. Has anyone else had this problem? I submitted an appeal which I requested to have expedited but it will still be 10 to 14 business days. I am so worried they are going to deny it again.

[Montereygrl 104]

Im very sorry to hear that, but most hospitals have a family house you can stay in almost for free, if cost is a factor. Even though my doctor is only 2.5 hours away I was scared to leave the hospital. Stayed in a hotel for a night just in case. I hope you don't let this discourage you. Have you tried to call and speak with a claims representative and tell them how far you would have to travel.

[sonya139 95]

My insurance will only approve it being done at a Center of Excellence as well.

[crodrigu73 13]

It would be a six hour drive for us. In addition to just the distance and the inconveniece of driving that far not only for surgery but once a month for follow-ups for a year, I have small children at home. I do not want to spend extra time away from them anymore than I have to be. The only reason my hospital is not a Center of Excellence is because it does not do over 100 bariactic surgeries a year. Otherwise it meets every requirement. I should be able to get the medical care I need where I live.

[NewAshes 232]

I hate to say it but if your insurance requires a center of excellence then they will most likely deny it again. my insurance also requires a center of excellence and wont do it any other way. A lot of insurance these days that do cover this require center of excellence.

[Aileen-March 2014 Sleeved 44]

You should see if the hospital that you are going to has been registered as a center of excellence most recently; and perhaps they have not been recognized as one yet with your insurance company. Or ask if they are in the process of meeting these standards of "excellence".

I work for a healthcare organization and I know that based on Quality of Care reports that are currently being implemented across the country; that your hospital choice may be waiting for State Health reporting. Just a thought. I know that the direction of healthcare is to get all hospitals on board with "Center for Excellence"

[crodrigu73 13]

They have applied and they have meet every requirement except the number of surgeries per year. They are required to perform 100 a year to be called a center of excellence however we just are not a very densely populated area.

[Tiny One 223]

Considering the closet COE hospital is hours & miles away, they just may grant an exception if that's explained in your appeal. So don't lose hope. Good luck & keep us posted.

[crodrigu73 13]

I am hoping so. I included in my appeal the impact traveling would have on my family, my employer, and my recovery. I also included the really cost impact to them as well as me if I have a hernia repair without the WLS. My surgeon estimates without it I will have another hernia within 6 months of having the infected mesh replaced. My last point was that two fellow co-workers received approval to have surgery at this exactly hospital this year (they had began their visits to the surgeon before we changed insurance on January 1st-no approval but they had started their visits). My thought is that if the hospital was acceptable for their surgeries it should be acceptable for mine.

[Montereygrl 104]

Don't give up, keep fighting!

[Superfluous 19]

How do you figure out where a COE is? Is there an online listing or something?

[crodrigu73 13]

This link should help you find one: http://www.surgicalreview.org/locate/

[Superfluous 19]

Wow. I hope my insurance doesn't require a COE, since the nearest one is 8 hours away! There are only 12 in the entire US!

[crodrigu73 13]

I think that maybe an old list. It doesn't have any showing in South Dakota, which I know is incorrect. There are two however they are 350 miles away from me. I would say go into your insurance website, there should be a location that will list all of the requirements for getting approval. I knew this part would be a little bit of a fight but I am hoping they will be able to see a patients point of view and the impact traveling this type of distance can have on the surgery and recovery.

[mlowell 39]

There can't be only 12 in the U.S......there are at least two near me that I know of. One is 30 min away and another one just over an hour away