Please help, I just got a denial letter from my surgeons office saying that I didn't have 2 comorbids that have not responded to maximum medical management that are generally expected to be reversed or improved by bariatric treatment!!!!

My BMI is 35.6 my comorbids are a high cholesterol of 254 and sleep apnea. I have had high cholesterol for years with no medication and I have had a sleep study done years ago but I dont use a cpap. Any ideas on how to appeal this decision?? My surgeon's office submitted all other requirements. I have tried other weight loss methods like weight watchers, used phen phen, atkins diet, dexatrim, slim fast, scarsdale medical diet, grapefruit diet, etc..Any info would help... I am desperate !!! I am scheduled for surgery on November 4th supposedly. Very upset and can't stop crying here..

they want u to get tired n give up they will prolong it so u will do what I say keep on it

also in letter add family history and why u feel u need the surgery

also in letter add family history and why u feel u need the surgery

Good advice! I wasn't approved for the sleep apnea test. When I called my insurance, she recommended telling the doctor to be explicit and add as much to their notes as possible. I told my surgeon. I got approved for my Sleeve within one week. I called 3 days to see where it was in approval stage. Lol

I have BCBS of New Jersey (Horizon) and was approved with a 35 BMI, high cholesterol (256) and sleep apnea so our stats are very similar. You may want to see if you need a more recent sleep study, go through with getting a CPAP machine and have your PCP give you a prescription for one of the staton drugs (I take Lipitor). I was able to show that I was being treated for these conditions - which may have made the difference. Just my 2 pennies. Whatever you do, though, don't give up.

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I have BCBS of New Jersey (Horizon) and was approved with a 35 BMI, high cholesterol (256) and sleep apnea so our stats are very similar. You may want to see if you need a more recent sleep study, go through with getting a CPAP machine and have your PCP give you a prescription for one of the staton drugs (I take Lipitor). I was able to show that I was being treated for these conditions - which may have made the difference. Just my 2 pennies. Whatever you do, though, don't give up.

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So do you think if I get a updated sleep study and a just a prescript for high cholesterol would work?How long would I have to be on meds before I could be approved for surgery??

So do you think if I get a updated sleep study and a just a prescript for high cholesterol would work?How long would I have to be on meds before I could be approved for surgery??

If it were me I would run this scenario by the surgeon's coordinator who has been handling your case with the insurance company this morning. If they are in agreement, they can arrange he for the study and maybe the medication. I was only on CPAP a month prior to my surgery as my apnea was discovered during my sleep study.

The whole situation you are in seems so strange to me because you have the conditions under which they cover surgery. I just don't understand their position. Keep posting as you find out more and know you have support on this forum.

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I have Boeing BCBS too, and was denied last summer. Not only do you have to have the two co-morbidities, you have to show that they aren't responding to maximum medical treatment. I have been working with three doctors since the summer to show a track record. Two doctors have put in my file that my arthritis will only be helped with weight loss. Now I'm working with the sleep doctor because I am having trouble tolerating the CPAP. You have six months to apppeal after they deny you. My surgeon didn't tell me about the not responding part, I thought I only had to have two co-morbidities. I am trying to be very thorough so they will approve me this time. Good luck!

I was denied again after my surgeon had a peer to peer consult with my insurance medical management physician. It is the "no documentation that I have responded to MAXIMUM MEDICAL MANAGEMENT". I am so devastated right now. If I try and gain weight to get to 40 BMI I would have to literally gain 40lbs! and then I would worry about being denied again! my surgery has been taken off the schedule after I have been on pre-op diet for a week ! No way to self pay they want $20,600 for surgery. I have contacted via email the obesity law people and I am waiting for a call from them. I am also waiting to hear from my actual surgeon to explain to me what exactly was said in peer to peer review.

For maximum medical management it sounds like I need to be put on cholesterol medication (WHICH I REALLY DONT WANT) and a CPAP which I don't want either. I was told to lose weight and exercise to lower these risks and have tried and failed. My only other option is Mexico but my husband is not supportive of this idea even though I have told him of all the success stories people here have had. He worries about who do I goto in the states for follow up care and if my insurance would cover the follow up care for a procedure they would not cover?? any ideas or thoughts on any of this ???

I was denied again after my surgeon had a peer to peer consult with my insurance medical management physician. It is the "no documentation that I have responded to MAXIMUM MEDICAL MANAGEMENT". I am so devastated right now. If I try and gain weight to get to 40 BMI I would have to literally gain 40lbs! and then I would worry about being denied again! my surgery has been taken off the schedule after I have been on pre-op diet for a week ! No way to self pay they want 20' date='600 for surgery. I have contacted via email the obesity law people and I am waiting for a call from them. I am also waiting to hear from my actual surgeon to explain to me what exactly was said in peer to peer review. For maximum medical management it sounds like I need to be put on cholesterol medication (WHICH I REALLY DONT WANT) and a CPAP which I don't want either. I was told to lose weight and exercise to lower these risks and have tried and failed. My only other option is Mexico but my husband is not supportive of this idea even though I have told him of all the success stories people here have had. He worries about who do I goto in the states for follow up care and if my insurance would cover the follow up care for a procedure they would not cover?? any ideas or thoughts on any of this ???[/quote']

I'm so sorry this is happening to you! When you talk to your doctor, could you ask him how long you would need to be on cholesterol meds and CPAP? I know it's not a great solution for you, but it seems like a better option than gaining weight to qualify. I do know that since my surgery my PCP has told me to discontinue the CPAP and has cut my Lipitor in half so it's not necessarily something you have to do permanently. Let us know what your doctor says and what you find out dorm the obesity law folks.

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The insurance says you have to have two co-morbidities that DO NOT RESPOND to maximum medical management. So just taking cholesterol meds isn't enough, you have to show that when you took them your cholesterol didn't come down.

It's really stupid, but that's what we're working with. I am about to re-submit my claim after working with multiple doctors for five months to try to document it. If it works, I'll let you know.

I was denied again after my surgeon had a peer to peer consult with my insurance medical management physician. It is the "no documentation that I have responded to MAXIMUM MEDICAL MANAGEMENT". I am so devastated right now. If I try and gain weight to get to 40 BMI I would have to literally gain 40lbs! and then I would worry about being denied again! my surgery has been taken off the schedule after I have been on pre-op diet for a week ! No way to self pay they want 20' date='600 for surgery. I have contacted via email the obesity law people and I am waiting for a call from them. I am also waiting to hear from my actual surgeon to explain to me what exactly was said in peer to peer review. For maximum medical management it sounds like I need to be put on cholesterol medication (WHICH I REALLY DONT WANT) and a CPAP which I don't want either. I was told to lose weight and exercise to lower these risks and have tried and failed. My only other option is Mexico but my husband is not supportive of this idea even though I have told him of all the success stories people here have had. He worries about who do I goto in the states for follow up care and if my insurance would cover the follow up care for a procedure they would not cover?? any ideas or thoughts on any of this ???[/quote']

You have to jump through the hoops the medical insurance wants to get approved. Like it or not. I felt like a poodle in a show, but I knew that is what would make them approve. You could appeal.

That's really rough, sorry :-(

my BMI was only a little over 40 (with no comorbidities), so the nurse at my bariatric office told me to be careful not to loose too too much weight before surgery to be sure I would be approved... Kinda a bizarre thought... I think my surgeon also told the insurance company that I have back pain from my weight (which I do, but it's a combination of weight and occupation), and fatty liver (from my abdominal US)... Not sure if that made a difference but I was approved no issue!

I would not eat your way to a BMI of 40. Call your insurance. Get a letter from your PCP saying they recommend the surgery. See if you can start meds for your cholesterol and get a cpap. Gaining more weight is not the answer.

I agree. Don't gain weight. That borders on insurance fraud.

With what i am paying AFTER insurance. Would have been cheaper for me to do mexico and finance it. Insurance is not all its cracked up to be.... After 80%, still paying just under 4000....

With what i am paying AFTER insurance. Would have been cheaper for me to do mexico and finance it. Insurance is not all its cracked up to be.... After 80%, still paying just under 4000....

Wow, my insurance was pretty good. I think i paid maybe $200 in copays for my specialist visits & $800 for my hospital stay., nothing more.

Skalleywag - I've been thinking of you - just checking in on you to see how you're doing. Has your doctor offered anything in the way of a plan forward?