DENIED Blue Cross and I'm RANGING with anger!

[Cody's mom 247]

@@Mom0f3inOC, it's not risky in Mexico at all. I would choose them over any doctor here as I feel they are at least held accountable for their work, can't say the same for American doctors. I went alone, and met so many wonderful people. I plan to go back for a little renovation work on my giggly parts. There was not one second that I didn't feel safe, and there you get GREAT surgeons, to me peace of mind and to be able to do what I know needs to be done was important, not to have a buch of people decide for me what's important and what I need. Just my thoughts and opinion.

I hope the insurance company comes threw for you as the sleeve is the most important thing I have done for myself EVER.

[JamieLogical 8,727]

@@Mom0f3inOC, it's not risky in Mexico at all.

Well, technically ANY surgery is "risky" but I would definitely not consider surgery in Mexico any more risky than the US, so long as you do your research in choosing a surgeon. Just like in the US, there are good surgeons and bad surgeons. There are also matters of personal preference to factor in, such as whether you would prefer to have surgery in a hospital or clinic. As for actually visiting Mexico, I have been there ton two occasions for surgery and felt 100% safe on both trips.

[Mom0f3inOC 11]

Thanks for the thoughts on Mexico. I might start thinking more seriously about that if things don't work out there. I do like the American doctor who did my band, and he is the one who would be doing the sleeve, if I get approved.

I got a little bit more info from the insurance company.

In general the surgery was deemed “too investigational.”

The peer to peer is on Tuesday and I have no idea what to expect.

Edited March 5, 2015 by Mom0f3inOC

[Mom0f3inOC 11]

i was denied twice and made it on the third appeal. im two months post op now, so it does work.

Steve, Do you have any advice? Any steps to take, words to use, requests of doctor? Etc. Why were you denied and what happend that eventually caused you to be approved? Please share.

[sandyb68 46]

I know the feeling. My insurance through my employer would not even consider covering this surgery. I had made my mind up and was so determined that my husband just told me to go ahead anyway. yeah, I now have a huge credit card bill to pay, but I have not had any second thoughts. 2 weeks out and I am down 49lbs today and could not be happier. I consider the amount of money I use to spend on eating and drinking out every day will now just go against paying off the credit card. Good luck with your appeal.

[Lani789 128]

Are you involved in the review? I would fight by my putting an album of pictures over the past years together so they can see your size. Include pictures with kids, dogs, etc. don't use the "pretty" pictures and let them see what your size looks like. I believe there is a human element to approvals in some cases and we need to reach out to make sure they see us as humans, with a full life and family, not just a form. My insurance nurse actually choked up at one point when I answered a question, then she said well we will fix that. Surgery approval like four days later.

[JamieLogical 8,727]

The peer to peer is on Tuesday and I have no idea what to expect.

Best of luck!

[Pac-woman 325]

Nevermind. I simply repeated what I have read from others on here. I don't condone it, but I have read from others on these forums that is what they have done. So the statements were already there. However, you are right.

Once the poster calms down, I am sure she will think it through a little better and works it out. Appealing is always the way to go whether it is done by the provider or the patient.

Do as you will.

Edited February 28, 2015 by Pac-woman

[LipstickLady 25,682]

So uhmmm.... I totally wouldn't talk about committing insurance fraud here. I am positive that @@Alex Brecher would not encourage that on his site.

[Jovie62 135]

I agree with LipstickLady. Dealing w insurance is never easy

[BLERDgirl 6,417]

Thanks for the thoughts on Mexico. I might start thinking more seriously about that if things don't work out there. I do like the American doctor who did my band, and he is the one who would be doing the sleeve, if I get approved. Also, I have excellent coverage (for what actually gets covered!). I would pay only about $500 for the surgery and all additional care related to the procedure (again, if approved), so doing it here in the US is a good "plan A" for me.

I got a little bit more info from the insurance company.

In general the surgery was deemed “too investigational.” Here are their reasons

The insurance company said there was not a well documented problem with the band.

I assume that means the doctor did not build a strong enough case for there being a problem with the band. He told me there was "likely a slip" and I'm guessing that the word "likely" is the main problem.

Insurance company also said there was no documentation showing that I have followed a diet and exercise plan.

The nutritionist and internist both took and extensive history of all that I have tried over the last 10 years. Weight watchers, My fitness pal, gym memberships, Zone, etc. I am assuming the insurance company wants a 6 month supervised diet, but according to my policy, if I have the procedure before March 15 I am not required to do the supervised diet. I'm scheduled for March 13.

The peer to peer is on Tuesday and I have no idea what to expect.

Those are the point you prepare for. Make sure that you have a chance to speak. Prepare by sitting down and writing out your responses. Review it carefully. It helps to use their language back to them. Be positive but also determined. (not rude). The key I have found with systems like this is trying to think of all possible ways they could say no and coming up with prepared rebuttals.

1. You doctor reported you "likely" had slippage. List each and every symptom and problem you are having with the lap band. Make sure to list them all no matter how minor.

2. Point out the deadline discrepancy. Make a copy of the information as listed in your policy or their online website. Point out that the nutritionist and internist were monitoring your weight while you were attempting to eat sensibly and exercise. Perhaps even mention that the lap band complications made this challenging. (if this is indeed true). Talk about your co-morbs. You want to play up the worse case scenarios while still being honest.

Most of all fight for this. Appeal until there are no further appeals left.

Edited February 28, 2015 by BLERDgirl

[dadempsey 5]

Makes me sad that you have to fight so hard for your life. You almost start collecting co-morbidities just to get approved. When I started this journey, I would look at my co-morbidities and hope for more just so I did not have to go through all of the disappointments insurance could throw at you. I finally got my 'golden ticket' and developed type 2 diabetes. Do I really want diabetes? Heck no! but for this purpose, yes,I am more secure in having the surgery. Sad but true.

[samuelsmom 670]

Excellent advice from Blerdgirl. Definitely follow it. Also, they might want to know what you are doing currently for fitness so be prepared by making a list of your activities.

[Nikkidoodlebug 120]

I would just go to mexico!! "Just sayin"

[roundisashape 712]

Definitely appeal. I know it's frustrating, but insurance companies make bad calls and mistakes all the time - heck, I was approved, had the surgery, then got an $11,000 bill because they messed up and denied the whole thing. BCBS admits they made a mistake, but it's taken them almost 3 months to correct it.

I'm just saying, don't assume that their first decision is their final decision or that they accounted for all the details of your case the first time around. It's worth making the effort to appeal before you give up.