Insurance denied ?

[healthymom2012 2]

I’m just wondering why insurance companies would deny you?

[Sosewsue61 3,185]

1. Bariatrics not covered in ins plan

2. Did not meet criteria. Ex. <40BMI no comorbidities, or <35BMI w comorbidities; Did not follow a 6 month supervised plan diet and exercise plan; fail tests - pysch eval, stress tests, or any other physical reason surgery is contraindicated.

Those are the main reasons you could be denied, or postponed until you are compliant.

[healthymom2012 2]

1. Bariatrics not covered in ins plan
2. Did not meet criteria. Ex. Those are the main reasons you could be denied, or postponed until you are compliant.

Seems very straight forward. Those all things that I knew a head of time. I guess I’m wondering why people seem so nervous about getting denied???

[Sosewsue61 3,185]

There can be mistakes made when the clinic files too if they are unfamiliar with certain insurances.

And I forgot - some insurances want you to follow the 6 month diet, and if you successfully lose too much weight by falling below the required BMI they could deny, also some have a strict 'no gain rule' during that 6 months too. And the EXTREME insurance that requires 5 years of documented attempts at weight loss. The last one I have seen two people on here struggling to find 6mos missing records - those may as well just say 'we don't cover wls' but may be required to by state law but then make dang sure it is close to impossible to qualify.

[healthymom2012 2]

There can be mistakes made when the clinic files too if they are unfamiliar with certain insurances.
And I forgot - some insurances want you to follow the 6 month diet, and if you successfully lose too much weight by falling below the required BMI they could deny, also some have a strict 'no gain rule' during that 6 months too. And the EXTREME insurance that requires 5 years of documented attempts at weight loss. The last one I have seen two people on here struggling to find 6mos missing records - those may as well just say 'we don't cover wls' but may be required to by state law but then make dang sure it is close to impossible to qualify.

Right and these are all things people should know a head of time about their insurance.
My BMI needs to stay at 40 but I have co morbidity so I would be ok if I fell below that. I also need to show that 40BMI for 6 months. My doctors office has been amazing with making sure I’m in compliance with my insurance company.

[KimTriesRNY 1,853]

28 minutes ago, healthymom2012 said:

Seems very straight forward. Those all things that I knew a head of time. I guess I’m wondering why people seem so nervous about getting denied???

Sometimes people are nervous because they have tried at losing weight and failed many times. Surgery is a drastic and last step option for many of us that made this decision.

There is an emotional component to it that is part of being human other than “well my paperwork looks ok, so I should be approved lickety split.”

Many insurance companies, even if they cover WLS, have denied coverage for people for seemingly minute details and if you hang out here long enough I’m sure you’ll read some stories about it.

Just because an insurance company covers an expensive procedure doesn’t mean they want to for everyone, and in fact in some states they are mandated to by law, so there are lots of hoops to jump through.

[healthymom2012 2]

Well I hope I’m approved lickety split!!

[KimTriesRNY 1,853]

19 minutes ago, healthymom2012 said:

Well I hope I’m approved lickety split!!

I hope so too. I hope everyone that finds themselves at this point is.

You seemed incredulous as to why people are nervous waiting to be approved. Just was trying to make a point it’s not an easy road for everyone.

[aNYCdb 310]

Because insurance companies make more money when they don’t have to pay for things. Their business model revolves around finding any excuse to deny you, sometimes even if it’s not a legitimate excuse.

[KimTriesRNY 1,853]

5 minutes ago, aNYCdb said:

Because insurance companies make more money when they don’t have to pay for things. Their business model revolves around finding any excuse to deny you, sometimes even if it’s n

This.

[healthymom2012 2]

I hope so too. I hope everyone that finds themselves at this point is.
You seemed incredulous as to why people are nervous waiting to be approved. Just was trying to make a point it’s not an easy road for everyone.

Guess I was just being naive and curious why people were nervous. I know a couple of people who had WLS with no issues with insurance. Now I’m nervous reading everyone’s posts. I was hesitant about joining a forum...this why. No need to be nervous if I wasn’t before! Lol

[Frustr8 7,886]

And my friends, based on my own experience, sometimes the refusal is not the insurance, but someone else. Sometimes it truly is the insurance, but other times someone hides behind that. And it leaves a taste like bitter bile in your mouth and in your life. 😢

[healthymom2012 2]

And my friends, based on my own experience, sometimes the refusal is not the insurance, but someone else. Sometimes it truly is the insurance, but other times someone hides behind that. And it leaves a taste like bitter bile in your mouth and in your life. [emoji22]

Ah I see. Ok well thanks for info.

[KimTriesRNY 1,853]

1 hour ago, healthymom2012 said:

Guess I was just being naive and curious why people were nervous. I know a couple of people who had WLS with no issues with insurance. Now I’m nervous reading everyone’s posts. I was hesitant about joining a forum...this why. No need to be nervous if I wasn’t before! Lol

A great many of us were approved on first submission to insurance.

If you have all your requirements met, and your paperwork is sound, and your insurance company doesn’t have a reputation for unnecessarily denying the procedure, certainly why worry yourself sick and read a lot of worst case scenario posts.

This forum is so much more than about what comes before surgery though. It’s the support in here that comes after surgery that is so valuable. There’s many people in here in all stages of surgery to connect with.

[Creekimp13 5,841]

Sometimes there's some wild card arbitrary reason to delay or turn you down that turns up....

Rule's like.....The sixth months of monitored weight lost must be consecutive with no more than a 45 day gap between appointments....and you had a 47 day gap because of your doctor's vacation.

Or.....

We need you to have a 40+ BMI that has been documented for 2 years and we can't find a weight that high more than 18 months ago.

Or....

We've recently changed our guidelines to eliminate two of the co-morbidities that you were counting on using.

Stuff like that.

It happens.

Doctors will throw in additional tests for additional health issues, too.

For some folks...it's a hold their breath situation until they're finally in the clear....because they've experienced being disappointed in the past.