Insurance Denial

[ccol625 14]

I received the call from BC/BS that my procedure was denied due to my BMI being too low. They have my BMI as 36.6, however when I calculate I get 38.73, so I think they have the incorrect weight and height from my doctors office. Although, I have some co-morbidities, I don't have any MAJOR ones so they say I'm not a candidate. I told them so if I gain 6 lbs and have a BMI of 40, I would be approved and they said yes. Well guess what I plan on doing?

My doctors office said they will appeal and if the written appeal gets denied, then they will ask for a peer to peer meeting. I am scheduled for the sleeve on 3/31 so I am hoping the news will change before then or else I will be eating everything in site so I can gain 6 lbs and have a higher BMI. It really SUCKS that I have to gain weight to get approved.

Anyone have any advice on how to get approved without gaining weight?

[ccol625 14]

Oh BTW, I am heartbroken about this denial too. I am a single mom and had it all planned out to have the surgery done the week my kids were on spring break so they could go to their grandmas house so I wouldn't have to worry about getting someone to bring them to school and back etc. I don't know what I will do if I can't have this done at the end of the month.

[Pepper123 320]

Awww talk to your surgical coordinator she or he should be able to help!!!…good luck!!

[ccol625 14]

Thank you Pepper123 but the surgical coordinator is the one that said she would submit the written appeal and if that got denied she would submit for a peer to peer review/meeting

[samuelsmom 670]

I would talk today (if possible) to the insurance person about timing. My kids are older now, but I remember all the planning for stuff around the kids school schedule. If you haven't already let them know how important the date is, it might be a good idea to do so.

Also, write a letter and email it to the insurance company. Tell them about your journey and why you are seeking surgery. Tell them about the co-morbidities you do have and how it negatively affects your life. Tell them how you feel it is counter-productive to gain 6 pounds just to be approved.

Honestly, I completely get that you don't want to gain weight. That being said, I could easily gain 6 lbs in a weekend! Lol.

Edited March 9, 2015 by samuelsmom

[ccol625 14]

@ samuelsmom, thank you for your advice. I have written an appeals letter and emailed it today. I also called the case manager and left a message. Of course she called me back but I missed the call because I work in a hospital myself and was tending to a patient. Called back again and left another message.

The surgical coordinator also contacted me saying she called the case manager on Friday and left a message but hasn't heard back. She will try again this afternoon if she hasn't heard anything.

And yes I think I could easily put on 6 lbs over a weekend as well.

Wish me luck!!!

[cdenney123 103]

I gained in order to qualify and it was all worth it I lost what I gained just on the pre op liquid diet. Good Luck

[ccol625 14]

@cdenny123, thank you because I think that is the route I will have to go down.

Did you gain before the 1st consult or during the "supervised diet" nutritional visits?

Do you know if they base this on your first /original weight or the most recent?