Anthem denied

[Knitchic 97]

Good evening everyone. I recently had my bypass and now my best friend is trying to get approval. She received a letter in the mail today from Anthem BCBS stating she was denied stating she didn't meet the criteria. She has 12 months Doctor supervised weight loss psych eval and nutritionist approval.

I would love any tips to help get her approved.

[RILEYSMOM22 344]

Good evening everyone. I recently had my bypass and now my best friend is trying to get approval. She received a letter in the mail today from Anthem BCBS stating she was denied stating she didn't meet the criteria. She has 12 months Doctor supervised weight loss psych eval and nutritionist approval.

I would love any tips to help get her approved.

What is her BMI?

[Mom26 313]

A friend was denied 3 times. She finally put together pretty much a novel, including letters from the gym owner, her doc, etc - that detailed a few years of trying to lose weight. They approved within a week after that. Hopefully your friend can show them her attempts and have them approve. But if her BMI isn't "high enough", do they require co-morbidities? Does she have any?

[linzlou2000 193]

I am working on the 12 month BCBS program. Did she do the once a month phone call with her coach?

[simply.me.vsg 6]

That's odd. Anthem BCBS approved me with 1 year supervised dietician visits and my psych evaluation.

[Knitchic 97]

I would guess her BMI is around 42 or 43 because she is short. She has multiple comorbidities (high blood pressure, pre diabetic and such). She has met with a doctor monthly for the last 12 months.

[linzlou2000 193]

I graduate tomorrow from my program with BCBS and my insurance request will be submitted. I'll flip a lid if I'm denied. I've waiting 12months, plus a day. I've done everything they've asked. I still qualify by their terms. If I'm denied---it won't be pretty. Praying your friend can get answers. That's crazy she's done her part for a year and they said no.

My program was through BCBS with MyActiveHealth. I couldn't just have 12 months of MD visits. She needs to ask for her member handbook and find out exactly what was required. Did she have to use "their" people for the 12 month program maybe verses her MD?

Edited September 29, 2015 by linzlou2000

[heynowkc 329]

Yeah I also had Anthem BCBS and did the 12 months with a MyActiveHealth coach. If she didn't do the MyActiveHealth bit, that may be the reason she was denied.

[jess9395 5,448]

Every anthem blue cross plan is different depending on who you are contracted through (employer, open market, etc). Some even have riders that say that don't cover any WLS. You have to check your particular plan. I was super lucky and didn't have to jump through any hoops except the pre op clearances. Got all those done in four weeks and a speedy approval.

Your friend needs to check her particular plan. If she seems to meet all the requirements and there is no rider saying they don't cover it, it's easy to appeal or request a "peer to peer" review where her surgeons office talks with a doctor who works for the insurance company.

[linzlou2000 193]

Yeah I also had Anthem BCBS and did the 12 months with a MyActiveHealth coach. If she didn't do the MyActiveHealth bit, that may be the reason she was denied.

I thought I was a loner!!!!! Thanks for letting me know someone else survived the 12 month program!!!

Edited September 29, 2015 by linzlou2000

[heynowkc 329]

@@linzlou2000 Yeah I didn't see many people who had to do a 12-month program, let alone the 12 months of coaching. Very glad to know I'm not the only one. Looks like your surgery is coming up! I'm just over 9 months out. Good luck to you!

[JacksdadShane 65]

Weird I was approved by Anthem with 6 months weigh ins, psych eval, and 1 support group meeting. I would call and find out what they mean.

[perk4756 259]

Mine is also just 6 months but every plan is different. My husbands employer has an add of this. All BCBS is different.

[MsMe 22]

Today I was denied by Anthem Blue Cross. My doctor is going to appeal with a peer to peer review. My doctor's office said they aren't sure if they can complete the whole process on time ( Dec 1st my insurance changes to Blue Shield of CA) my BMI is 35.5 I have sleep apnea normal blood pressure, high risk for diabetes but not diabetic, high cholesterol. They denied me said it wasn't enough to qualify. I'm so devastated. I hadn't been so excited about my future since I can't remember. The doctors office said they rarely have a denial & they never lost an appeal so I'm not confident but still want to hold out for hope. If anyone has any suggestion or experiences that are similar please advise. Thank you

[linzlou2000 193]

Thinking of you and hope they get you approved.