Insurance Denial - Any who have had insurance denied?

[Solmar 5]

Hi,

My surgery date is scheduled for November 18th. I got a call from my surgeons office saying that I was denied. Because 1) I have sleep Apnea yet no record of a Cpap Machine. 2) I am not on meds over 3 years 3) BMI less than 40.

I've provided everything asked of me.

1) Two letters from my physicians stating that they recommend me for Bariatric Surgery and provided a history. Strong letters from the doctors.

2) I've been on a Water pill for about or close to 2 years for water retention.

3) I was diagnosed with Moderate Sleep Apena

4) At the time I was seen I had 36.9 BMI, but my BMI is 38.9 per a wellness screening done.

I have done everything the surgeons office has asked me to do and to find out a week prior to surgery that I am not approved is frustrating.

I asked that they do a peer to peer. It's a lot of time invested, money, Vitamins, Proteins purchased. And, I am already paying my copays for the endoscopy done and lab work etc...

Anyone has gone through this , and finally got approved? I need some hope. Tomorrow I will know for sure. If not I will need to do self pay.

[Tobeornottobe 89]

Are they going to do a peer to peer review? There is still hope. Don't give up.

[Solmar 5]

@@Tobeornottobe - yes, they are going to do a peer to peer review. I also called the insurance company to appeal and was told that the surgeon can appeal. It is scheduled for tomorrow. I am gonna turn on candles and pray (Catholic) for this to go through. I hate to have to touch my husbands 401K and use our retirement fund for this surgery but I've invested so much time, effort, gone to visits, psych, heart, lung, endoscopy, to let it all go to waste. On top of it. I am already paying the remaining balances that all these visits and tests have incurred. Please send me good vibes, I need all I can get.

[ssflbelle 829]

I am so sorry to hear the insurance is doing this to you. I hope the surgeon can convince everyone during the peer to peer review of the need for you to have the surgery. When I was denied in 2008 for the lapband. I told the Dr's staff I didn't care what they did but I was not about to pay for all the classes etc that the insurance would not pay for. Well they worked some kind of magic with the codes or too a loss as I never got a bill for any of the different classes I had to take back than. Now I am in my 6th month of a supervised diet and I am hoping and praying this new insurance will not deny me the sleeve.

Please let us know the outcome. I WISH YOU THE VERY BEST!!!

[Tobeornottobe 89]

@@Tobeornottobe - yes, they are going to do a peer to peer review. I also called the insurance company to appeal and was told that the surgeon can appeal. It is scheduled for tomorrow. I am gonna turn on candles and pray (Catholic) for this to go through. I hate to have to touch my husbands 401K and use our retirement fund for this surgery but I've invested so much time, effort, gone to visits, psych, heart, lung, endoscopy, to let it all go to waste. On top of it. I am already paying the remaining balances that all these visits and tests have incurred. Please send me good vibes, I need all I can get.

@@Solmar, sending positive vibes that all goes well with the peer to peer. Honestly, sometimes, the peer to peer does the trick. It maybe a small unanswered question the insurance company needs answered. This will all work out and you'll be ready to go in no time.

[Champ715 207]

Why were you not aware of your insurance requirements prior to having surgery scheduled? I had to do a 6 month process and the very first thing I did was print off the requirements from my insurance company so I knew if I was qualified or not. I would never have invested a lot of money if I wasn't even qualified.

[2goldengirl 2,076]

Why were you not aware of your insurance requirements prior to having surgery scheduled? I had to do a 6 month process and the very first thing I did was print off the requirements from my insurance company so I knew if I was qualified or not. I would never have invested a lot of money if I wasn't even qualified.

EXACTLY. Always, always, find out your insurance requirements BEFORE moving forward. They are often available by simply googling "nameof nsurance company medical policy bariatric surgery" insurance company name medical policy weight loss surgery or surgery for morbid obesity. It's so much better to know rather than feeling you have no control and fretting over it!

[Solmar 5]

@@Tobeornottobe - Hi All, I wanted to say that I was approved for surgery. The peer to peer review did come through.Thank God. I learned on Thursday. I faxed over some additional information that I thought would help. I don't know if that did the trick but 1/2 hour later, they called and said it was approved.

[Solmar 5]

@ southern sleeve - Yes, I knew the requirements not only did I know but also I was told by the coordinators at the doctors office what I needed. I provided everything I was asked to provide. At the time of my pre-op visit I asked my surgeon, have you heard from the insurance company and she said no, but I have no concerns because I am sure they will approve.

I received the letter today from the insurance company and it didn't make sense that they would disapprove me because I followed their protocol. Not sure if all the documents were submitted or not, but the end result is " I was approved for surgery".

[Solmar 5]

@ 2 goldengirl, in reply to your response, yes I knew what the requirements were before going into this. Also, as I was going to my visits the surgeons office contacted me at all times. When I visited my surgeon for the pre-op appt, I asked have you heard anything from the insurance company and she said no but I am not worried. Your insurance company is very good and I have no doubt that they will approve you.

Well, I was approved. The surgeon and insurance company did a peer to peer and was approved. I was notified Thursday.

[ssflbelle 829]

So glad to hear you were approved. I have searched online and found nothing about my insurance approval procedure. Before I started with the 6 month supervised diet I got a case manager from the insurance company and questioned her and questioned the staff at the Dr office about the approval procedure Everyone said I too will get approved. I was denied in 2008 for the lapband This is a different insurance company then in 2008. However I am still going through the cardiac and pulmonary clearance and have more testings to do. I am fearful I will not get approved again and am glad to hear that the peer to peer review worked for you. Now that I know about it I will use it if I have to. When do you found out your surgery date?

[Tobeornottobe 89]

@@Tobeornottobe - Hi All, I wanted to say that I was approved for surgery. The peer to peer review did come through.Thank God. I learned on Thursday. I faxed over some additional information that I thought would help. I don't know if that did the trick but 1/2 hour later, they called and said it was approved.

@@Solmar Brilliant!! I am so happy for you!

[Solmar 5]

@@Tobeornottobe - Thank you so much. You have no idea what I felt when I got that call. I work in an office and there are cubicles all around me. When I got the call , I ran into the office and said Yes, Yesss, Yesss

[Solmar 5]

@@ssflbelle - I got my appt at the time I had my initial consult. My surgery was scheduled 11/18th , this date was given to me back in July. They do 10 surgery cases Mon, Tues, and Wed.

My surgeons office know exactly what the requirements are, so anything they asked of me, I gave. That is why it was so surprising that they would deny me. Also, when I got the denial letter and read it, I had done all the requirements. Anyway, I am so happy that I am scheduled. I am on a pre-op diet now. My surgery is this Wednesday. Ive been reading a lot of postings that everyones diet is different. I