Denied by BCBS TN

[OBXhappy 28]

Received a letter from BCBS TN stating that my surgery has been denied, the reasons are:

My five year weight history does not show a presence of morbid obesity.

I knew that I did not have this proof going into the process. I don't go to the doctor unless I'm seriously ill so as it happened my weight was down (Due to dieting) at the one time in the year that I was at the doctor. My surgeons office assured me that would not be an issue. I questioned this at my first visit and took paperwork in on a second visit and discussed it with the nutritionist. I also have it in writing with a PA in the office stating, "It will not be a problem."

They did not receive documentation of a co-morbidity.

Not sure why this would not have been submitted as I had a sleep study and was diagnosed with sleep Apnea

They did not receive documentation from attending physician that I followed a non-surgical weight loss program within 2 years of surgery.

I've been on one type of diet or another for the bast 20 years. Like many obese people I didn't check in with my doctor prior to going on any of them.

I did not achieve or maintain 10% of weight loss

I did not know this was a requirement. My surgeons office didn't mention it, in fact they stated I wanted to be careful not to go below the 35 bmi. I had checked in with my insurance and this was not on the documentation sent to me.

This member only participated for 4.5 months a minimum of 6 months participation is needed.

I met with a nutritionist for 6 visits. Six months in a row. Evidently it was not submitted correctly.

A person from the surgeons office (not the particular office I've went to but one of their offices) called today to say that due to the missing 5 year history the surgeon will not do a peer to peer with the insurance office. After all that is a requirement by the insurance company and their isn't anything they can do about MY insurance.

To top it off I have a preop appointment with my pcp tomorrow as my pcp's office called me to set up an appointment since they were sent a date of May 5 by the surgeons office. When I asked the surgeons office about the date today she said, "Oh, we just put a date on the form for insurance purposes."

I'm at a loss. Trying to decide rather I sign up for Nutri-System again, or Weight Watchers etc. I've got to do something as I got rid of all my summer "Fat" clothes when I started this process as i was determined that I would be a thinner me by summer since I started this last August.

Anyone know of any wonderful diets that work.

[KristenLe 5,980]

How much do you have to lose? I would consider appealing the denial. Look at the Obesity Action Coalition website for suggested appeal letters. Maybe your PCP would consider doing a peer to peer with the insurance or writing a letter on your behalf informing them of your history with obesity.

[OBXhappy 28]

I would have had to lose 25 lbs. which I could have done. Had I known that was a requirement. I was basically told not to lose it because it would put be under the bmi requirement.

So, I've written a fairly detailed list of diets I've tried. The ones that worked etc. Do I submit this to my insurance or should I send it to my surgeons office and ask them to reconsider doing a peer to peer.

I do not have a history with my pcp because my pcp left on maternity leave and I have a new pcp for the past year. I've seen him twice.

[KristenLe 5,980]

Can you get records from any previous Drs? Look at the letter samples and info on the obesity action coalition and then call the person at the surgeons office that deals with this type of issue. I have no way of proving previous attempts either but I had to discuss them with the Nutritionist and Psychiatrist in my Bariatric Program. I have a very high BMI though so maybe that's the difference.

[kmorri 1,689]

@@OBXhappy How about a GYN....do you have 5 years of history with recorded weights with your GYN?......If you have the history with your GYN then provide that info to the surgeon and ask if he would do the peer to peer with that.

[OBXhappy 28]

Thank you for the suggestion. That was the one time I was at the Dr's in 2012. It was a GYN appt. I had been on a diet trying to lose weight for my daughters wedding. MY BMI is under 35 for that year. I had explained that to my surgeons office on my first visit. I'm so frustrated. I'm thinking of asking an attorney to assist with an appeal.

If by any chance I win an appeal. I will use a different surgeon.

[kmorri 1,689]

Before you go that route you'd probably be better off to go self-pay.....You should for sure do what someone else suggested and check out Obesity Action Coalition website they have information that can help you submit your own appeal.....you really don't need a lawyer for that..... I retired from BCBS of Florida. An appeal is not difficult but you do have to have all your ducks in a row. You have to focus on providing them information that proves you meet their criteria......and remember the fact that someone at the doctor's office didn't tell you about a requirement won't matter to the insurance company.....just focus on providing information showing them you do (Use their denial letter as an outline of the requirements you need to prove)......if there's a requirement they have that you don't qualify for write a very compelling letting outlining the reasons you need this surgery so badly........if there are requirements you absolutely don't meet the chances of you being approved are not very good and a lawyer won't make a difference.....But if I were in your shoes I certainly wouldn't give up without doing the appeal myself. Good luck to you!!!

Thank you for the suggestion. That was the one time I was at the Dr's in 2012. It was a GYN appt. I had been on a diet trying to lose weight for my daughters wedding. MY BMI is under 35 for that year. I had explained that to my surgeons office on my first visit. I'm so frustrated. I'm thinking of asking an attorney to assist with an appeal.

If by any chance I win an appeal. I will use a different surgeon.

[OBXhappy 28]

Thank you so much for your input. I have started an appeal letter and while I wouldn't mention anything about where I feel the surgeons office misled me. I did plan to briefly list each reason I was denied and how I meet the criteria. I am waiting for my medical records to be sent to me before filing the appeal.

I had thought about contacting Lindstrum at wlsappeals.com Truthfully, I think I could handle the appeal letter and if worse comes to worse in 8 months it is a new year and I would then have a 5 year history. Right? I guess it just seems important enough to hire someone who has experience in filing appeals. I know my field of expertise and insurance is just not it.

You have given me a lot to think about. I will sit down and make sure I have all documents in order. I haven't given up yet.

[kmorri 1,689]

Sounds like yo're on the right track......just make sure to provide all the documentation you can get your hands on.....I think you said several of the denial reasons shouldn't apply..... i.e. Where they say you only had 4.5 months and you say you have 6 months.....make sure to not just "say" you have the 6 months but provide that documentation....same with any of the others............and with regard to the 5 years of weight history....you'll need to just be creative in your letter explaining you've been obese for x number of years but have never seen a doctor on a regular basis and have "dieted" for all your life so of course there have been times your weight has been lower, but you've never been able to maintain....blah blah blah

But yes if this doesn't work, and if in January you'll have the 5 years you can look towards that. Again good luck!

[BBweightlossjourney 49]

Received a letter from BCBS TN stating that my surgery has been denied, the reasons are:

My five year weight history does not show a presence of morbid obesity.

I knew that I did not have this proof going into the process. I don't go to the doctor unless I'm seriously ill so as it happened my weight was down (Due to dieting) at the one time in the year that I was at the doctor. My surgeons office assured me that would not be an issue. I questioned this at my first visit and took paperwork in on a second visit and discussed it with the nutritionist. I also have it in writing with a PA in the office stating, "It will not be a problem."

They did not receive documentation of a co-morbidity.

Not sure why this would not have been submitted as I had a sleep study and was diagnosed with sleep Apnea

They did not receive documentation from attending physician that I followed a non-surgical weight loss program within 2 years of surgery.

I've been on one type of diet or another for the bast 20 years. Like many obese people I didn't check in with my doctor prior to going on any of them.

I did not achieve or maintain 10% of weight loss

I did not know this was a requirement. My surgeons office didn't mention it, in fact they stated I wanted to be careful not to go below the 35 bmi. I had checked in with my insurance and this was not on the documentation sent to me.

This member only participated for 4.5 months a minimum of 6 months participation is needed.

I met with a nutritionist for 6 visits. Six months in a row. Evidently it was not submitted correctly.

A person from the surgeons office (not the particular office I've went to but one of their offices) called today to say that due to the missing 5 year history the surgeon will not do a peer to peer with the insurance office. After all that is a requirement by the insurance company and their isn't anything they can do about MY insurance.

To top it off I have a preop appointment with my pcp tomorrow as my pcp's office called me to set up an appointment since they were sent a date of May 5 by the surgeons office. When I asked the surgeons office about the date today she said, "Oh, we just put a date on the form for insurance purposes."

I'm at a loss. Trying to decide rather I sign up for Nutri-System again, or Weight Watchers etc. I've got to do something as I got rid of all my summer "Fat" clothes when I started this process as i was determined that I would be a thinner me by summer since I started this last August.

Anyone know of any wonderful diets that work.

Hi @@OBXhappy ! I'm so sorry to hear of your denial.. I wouldn't give up .. Especially since you were told that you some of your initial concerns wouldn't be a problem. Call your surgeons office and demand for an appeal to be submitted in your behalf and tell the office to have the paper together with supportive documents. Stay on it! This happens often ,but you will have it approved if you stick with it ! All the Best to you !

Also...

On the other side , to answer your question regarding successful diets, I was on Phentermine for 7 months and I lost 80lbs.. Ask your Doctor about it, and. Google it and do your research .

I look forward to hearing about your progress !

Take Care !

[OBXhappy 28]

Received a letter from BCBS TN stating that my surgery has been denied, the reasons are:

My five year weight history does not show a presence of morbid obesity.

I knew that I did not have this proof going into the process. I don't go to the doctor unless I'm seriously ill so as it happened my weight was down (Due to dieting) at the one time in the year that I was at the doctor. My surgeons office assured me that would not be an issue. I questioned this at my first visit and took paperwork in on a second visit and discussed it with the nutritionist. I also have it in writing with a PA in the office stating, "It will not be a problem."

They did not receive documentation of a co-morbidity.

Not sure why this would not have been submitted as I had a sleep study and was diagnosed with sleep Apnea

They did not receive documentation from attending physician that I followed a non-surgical weight loss program within 2 years of surgery.

I've been on one type of diet or another for the bast 20 years. Like many obese people I didn't check in with my doctor prior to going on any of them.

I did not achieve or maintain 10% of weight loss

I did not know this was a requirement. My surgeons office didn't mention it, in fact they stated I wanted to be careful not to go below the 35 bmi. I had checked in with my insurance and this was not on the documentation sent to me.

This member only participated for 4.5 months a minimum of 6 months participation is needed.

I met with a nutritionist for 6 visits. Six months in a row. Evidently it was not submitted correctly.

A person from the surgeons office (not the particular office I've went to but one of their offices) called today to say that due to the missing 5 year history the surgeon will not do a peer to peer with the insurance office. After all that is a requirement by the insurance company and their isn't anything they can do about MY insurance.

To top it off I have a preop appointment with my pcp tomorrow as my pcp's office called me to set up an appointment since they were sent a date of May 5 by the surgeons office. When I asked the surgeons office about the date today she said, "Oh, we just put a date on the form for insurance purposes."

I'm at a loss. Trying to decide rather I sign up for Nutri-System again, or Weight Watchers etc. I've got to do something as I got rid of all my summer "Fat" clothes when I started this process as i was determined that I would be a thinner me by summer since I started this last August.

Anyone know of any wonderful diets that work.

Hi @@OBXhappy ! I'm so sorry to hear of your denial.. I wouldn't give up .. Especially since you were told that you some of your initial concerns wouldn't be a problem. Call your surgeons office and demand for an appeal to be submitted in your behalf and tell the office to have the paper together with supportive documents. Stay on it! This happens often ,but you will have it approved if you stick with it ! All the Best to you !

Also...

On the other side , to answer your question regarding successful diets, I was on Phentermine for 7 months and I lost 80lbs.. Ask your Doctor about it, and. Google it and do your research .

I look forward to hearing about your progress !

Take Care !

My surgeons office has stated that the surgeon will not do a peer to peerl. I pleaded with them to no avail. I was on Phentermine in 2011 which is why my weigh in for 2012 is under the 35 bmi.

I agree with KMORRI obese people tend to diet constantly. So our weight varies quite a bit. I thought about going through photo albums and trying to find some photos that I could submit that would show I've always had a weight issue. I tend to avoid the camera so do not have many photos of myself. I've heard that it has worked for some.

Thank you for your thoughts!

[kmorri 1,689]

@@OBXhappy photos are not a bad idea....especially around holidays so they can be dated......But I do the same thing you do. When I'm at my heaviest I'll do anything I can to avoid having my picture taken......my photo albums alone probably look more like I don't have a weight problem......and just go really long periods of time with not having my picture taken...haha

[silverthreads 183]

I also had trouble documenting my weight over time. I went to the Weight Watchers location where I had been to meetings and they were able to print out all my weigh ins even though it was about 5 years ago. BCBS accepted that as evidence of the weight and attempts to lose. So perhaps WW or Nutrisystem might have some records you can use?

BCBS won't care what your doctor told you about it not being a problem so definitely don't rely on that in your appeal.

Sent from my iPhone using the BariatricPal App

[OBXhappy 28]

Edited April 24, 2016 by OBXhappy

[OBXhappy 28]

I also had trouble documenting my weight over time. I went to the Weight Watchers location where I had been to meetings and they were able to print out all my weigh ins even though it was about 5 years ago. BCBS accepted that as evidence of the weight and attempts to lose. So perhaps WW or Nutrisystem might have some records you can use?

BCBS won't care what your doctor told you about it not being a problem so definitely don't rely on that in your appeal.

Sent from my iPhone using the BariatricPal App

I sent copies of my WW and NutriSystem records to my surgeons office. I'm really not sure what they submitted so I'm waiting to get my records and then I will know what all I need to submit.

Thanks for the feedback.