Denied BCBS of AL - My PCP did not include diet & exercise info.

[CCHeather 2]

I am heartbroken and discouraged. BCBS of AL denied coverage for VSG because my PCP did not include the fact that we discussed diet and exercise in all the notes for my 6 mo. pre-op medically supervised diet. In addition, the patient navigator at my surgeon's office did not send my medical records going back to 2012 because my BMI is 41 and she assumed that I would be approved. BCBS of AL requires a BMI of 40 or above for 3 years or 35 with co-morbidities in place for all 3 years. My BMI has not been 40 for 3 years, but it has been 36 and above with sleep apnea. I have used a CPAP for 5 years -- HOWEVER, BCBS requires that the sleep test shows severe sleep apnea. 5 years ago, my sleep study showed moderate leep apnea. I am certain that if I had another sleep study now, it would be severe.

Has anyone out there had success with an appeal to BCBS of AL? I would be so grateful for any thoughts or guidance. I had my fiest consultation 18 mo. ago. My PCP did not code my 6 mo. of appts. as "medically supervised weight loss" because my insurance would not pay for the appts. She recorded my weight at each appt. and blood pressure - which is borderline hypertensive, and she occassionally wrote notes about my attempts to lose weight.

[BLERDgirl 6,417]

I would appeal and include all missing information. People on this board do appeals and get approved quite often. If you feel you need this then you should exhaust all avenues of appeals before giving up. Talk to your PCP and make it clear to her that she needs to provide that information.

[Ashlegal 525]

I received my first denial based on two mistakes, one was mine and the other was my NUT's.

I gained two pounds my last month of weigh ins. Yep, two pounds and they denied me! My weight had been fluctuating the same ten pounds in either direction for about eight months.

Then in my NUT's "final review" she stated that I had taken on the hobby of baking pies, breads, Cookies, muffins and other pastries. What she forgot to disclose was that I had taken on the hobby of baking raw/vegan/sugar free/gluten free/dairy free pastries to prepare me for my after surgery diet needs.

My surgeon's office called me and said "start over with a new six months of weigh ins and NUT appointments, we won't give up if you don't!"

I was approved two weeks after my last weigh in and am six weeks post-op. DON'T GIVE UP.