Hello y'all! I Hope you all have a Happy Valentines Day!

I have been working towards getting VSG for about a year now (partly my fault, was having 2nd thoughts). I got denied in July, for not having physician diet for 6 months... I finished the process of the 6 month diet in January, submitted and got denied again... Yep! AGAIN! This process is getting so frustrating. I'm definitely not giving up though. The reason behind my 2nd denial is that my insurance company wasn't happy with my PCPs notes. I will try to go to my surgeons office on Monday to get clear and precise information regarding the notes but I was wondering if anybody on here had any information about how their PCP wrote the notes regarding the diet... I will see him this Thursday... And resubmit for a 3rd time on Friday. Please keep in me your prayers. I have a BMI of 50 and 2 comorbidities... It's so frustrating to see many people with lower bmi's w no comorbidities get approved in 2 days (lol sorry I'm kinda bitter) I have my wedding this September so kinda anxious about that as well!! Ugh!! Thanks for allowing me to vent! ❤️

I have Blue Shield of Ca ( H M O )

Your doc should know what to write. In my opinion they should have been in contact with insurance for clarity, especially second time.

Appeal. Now. Blue Shield of CA H M O doesn't require six months any longer, and they haven't since July 31, 2015. You should never have been denied in the first place. So long as your surgeon and/or PCP documents your previous attempts to losewweight, that's good enough.

Here is the link to Blue Shield's medical policies: https://www.blueshieldca.com/provider/authorizations/clinical-policies/medical-procedures/policy.sp

You'll find the policy for bariatric surgery under "B". Your medical group or IPA may be unaware of the change, but they should have looked it up online before denying you. Blue Shield didn't do a good job of letting their groups know of the change. It delayed my process as well. It's your group that did the denial (Blue Shield contracts with them to process authorizations), but appeals are handled by Blue Shield directly.

Good luck!

Edited February 14, 201610 yr by 2goldengirl

Appeal. Now. Blue Shield of CA H M O doesn't require six months any longer, and they haven't since July 31, 2015. You should never have been denied in the first place. So long as your surgeon and/or PCP documents your previous attempts to losewweight, that's good enough.

Here is the link to Blue Shield's medical policies: https://www.blueshieldca.com/provider/authorizations/clinical-policies/medical-procedures/policy.sp

You'll find the policy for bariatric surgery under "B". Your medical group or IPA may be unaware of the change, but they should have looked it up online before denying you. Blue Shield didn't do a good job of letting their groups know of the change. It delayed my process as well. It's your group that did the denial (Blue Shield contracts with them to process authorizations), but appeals are handled by Blue Shield directly.

Good luck!

this is true.. if the group denies.. then the ins co. should of looked it over as to why.. and they should tell u specifically need to be approved