Denied! Now what do I do?

[Beauty+5 14]

It has been one of those days to say the least. I called my insurance to check the status of my recently submitted papers for approval for bariatric surgery. To my dismay I was told I was denied because it wasn't medically neccessary. How can that be? My BMI is currently 66 and my weight is 422. I have sleep apnea and yes I sleep with a machine. I am borderline diabetic. I have high blood pressure. I have high cholesterol. I've got arthritis in my lower back, right hip, and my pelvis, making it very painful to do anything. I have Sciatic Nerve damage. I have Carpel Tunnel in both arms, and hands. I am ALWAYS out of breath. EVERYDAY I live in misery from the pain, and yet they say its not "Medically Neccessary". Are you kidding me? So now they are requesting a Peer to Peer with my bariatric surgeon, and yet the lady that handles the insurance stuff at the doctors office says she hasn't gotten a request. When they told me they sent one over, and their waiting on a response by tomorrow or else that's their final decision. I don't know what to do. I have come to far to give up now. I made sure I got clearance from my PCP, the Pulomonary Doctor, the Cardiologist, and the Gastroenterologist, and they ALL said it was "Medically Neccessary" for me to have the surgery. I also sent the last 10 years of medical papers showing that I have been battling with my weight forever. So now what? Does anyone know about Peer to Peer meetings and what are the chances of approval after having one?

[MichelleTN 169]

I'd go to my Dr office tomorrow & call my insurance company on my phone & then hand the phone to the insurance lady at the Dr office. That way you know they have talked to each other. Kinda crazy but it might work. :-)

[Martene81 383]

I don't know about the peer to peer process but I would say please don't give up and hang in there! With all the issue that you have described I don't see how they denied you and I'm sure you'll get the approval after the peer to peer.

[phatfatgirl 100]

Wow @@Beauty+5 what insurance do you have? I'm so so sorry they denied you. I'm in utter disbelief they denied you.

[Beauty+5 14]

@@phatfatgirl I have Amerigroup Medicaid. I was and still am in disbelief. I mean I have EVERYTHING wrong with me and I'm in my 30's. Hopefully the outcome will be good in the end I go see my surgeon tomorrow so hopefully he can work some kind of magic. Lol.

[Beauty+5 14]

@@MichelleTN that is some good advice. I am going to do just that too. Lol. They know I am VERY straight-forward.

[Beauty+5 14]

@ Martene81 I was saying the same thing it just doesn't make any sense to me. I even have a Vitamin D deficiency where I have to take 50,000 IU of Vitamin D weekly, I get B-12 shots, because it is so low. That's just a couple of more things. You would think the size and the sleep Apnea would be enough. For goodness sake if I don't sleep with my CPap I literally stop breathing numerous times through the night.

[The Candidate 3,215]

That's absolutely ridiculous! Your BMI alone qualifies you. And your other health issue only reinforce it. Whatever happens you must appeal. They don't have a leg to stand on. I wish you the best of luck!

[SkinnyDown 409]

@@Beauty+5 I am so sorry to hear this news.

Don't give up. The surgeon might be able to advocate more for you.

This makes absolutely no sense.

[Bobbe Schu 53]

DON'T DO ANYTHING until you contact Lindstrom Obesity Advocacy. They can help you, I know. My peer-to-peer for band to bypass procedure was denied last week so at the advice of many on this site, I contacted them and THEY are appealing my case. Google them for contact information. You won't be sorry. I have a great deal of confidence that my decision will be overturned!

[Beni 1,484]

Doesn't make sense. You should qualify easily, APPEAL but take a look at the paperwork to make sure all the requirements are fulfilled, the denial could have been due to a technicality. Your BMI alone qualifies as medical necessary.

[sparksrn 65]

Don't give up, keep fighting for you life because you are literally fighting for your life!

[Beauty+5 14]

Good news everybody, my patient coordinator called the insurance company herself. The doctor she spoke with there is no need for a peer to peer, after reviewing my file she see's I am more then eligible for surgery. She said it is definitely medically necessary and it was APPROVED! Yay! Look at God work. Now my journey starts!

[Bobbe Schu 53]

That's WONDERFUL, WONDERFUL news!! CONGRATULATIONS!!! You will rest well tonight!

[The Candidate 3,215]

I'm so happy they came to their senses. And most importantly that you weren't forced to go through a long drawn out fight to achieve the same outcome. You have a wonderful, bright, and healthy future ahead of you now!