Denied

[chrispat123 11]

I called my insurance company IBC PPO back in August, they sent me a copy of the bariatric policy. BMI over 40, weight loss attemps, etc. This is for it to be covered under medically necessary. Is the what everyone else used or does everyone else have a bariatric rider?

The surgeons office said I was denied because I do not have coverage. I had to call the insurance company 4 times before I found someone who referred me back to the policy I was sent in August. I am so confused. I have been on the phone all day!

Curious if anyone else got the same run around. Fingers crossed I hear good news soon. Hoping I don't have to pay out of pocket.

[Sosewsue61 3,185]

Document all conversations, who you talked to, their title, ask for the denial letter, etc. The person may have put down incorrect information about diagnosis, or incorrect coding on the submission.

First on your policy do you meet that criteria? Do you have documented failed attempts at weight loss - like Weight Watchers weigh-in logs, or your doctor visits whete you weighed in and talked about weight loss?

Can you take your policy with you to the surgeon's office and call your insurance from there? Keep pushing.

You either have coverage or not, but it sounds like you have coverage. Is it through work or ACA? What state are you in?

Hang in there?

Edited January 13, 2020 by Sosewsue61

[New&Improved 1,780]

Yeah it's usually some kind of error on the forms

[GradyCat 3,692]

That is the common coverage for bariatric surgery, having a BMI 40 or over or a BMI of 35 or over with two comorbidity factors. The surgery has to be medically necessary for them to cover it under insurance. They're not going to pay for someone who doesn't need it to have it.

[chrispat123 11]

I called back on August 12th and the insurance company sent me a copy of a policy. According to that policy I met all the criteria. The past 5 months I have done all the requirements from the surgeon, cardiologist, sleep study, psych eval, endoscopy, and bloodwork. They submitted it to insurance, denied. From what the surgeons office found out is that my specific group # does not include that policy. On hold right now to file a members appeal. Not too hopeful. Seems like I will be stuck paying out of pocket.

[chrispat123 11]

Insurance is still telling me I am covered if its deemed medically necessary. They said to have the surgeons office appeal. The surgeons office is telling me to do a members appeal. Ugh, so frustrating.

[bmbutler2 6]

What does your company HR say? Corporations can carry different coverages under the same company than another corporation.

[chrispat123 11]

Its a small company, I am part of the HR department, lol. Our brokers aren't terribly helpful. I will reach out to them next if I get denied again.

Still waiting for an answer since it was resubmitted by my surgeons office. I am on the phone an hour every morning making sure it moves along. So frustrating.

[chrispat123 11]

Denied again. Now I have to do a members appeal, 30-45 days. They are still saying I don't have coverage even though every time I call to talk to customer service they say I do.

[FinallyLosingIt20 16]

On 1/27/2020 at 9:18 AM, chrispat123 said:

Denied again. Now I have to do a members appeal, 30-45 days. They are still saying I don't have coverage even though every time I call to talk to customer service they say I do.

Hi, can you tell me what happened with this? I had the same thing happen with UHC in February. Last week I exhausted my final appeal and the bariatric center told me I'd have to go somewhere else, because they do not offer a self pay or financing option.😨

[AlwaysCruising 100]

I know it has been a while, but wondering about your outcome.

It was not clear to me whether you were told that (a) your insurance policy covers bariatric but you didn’t meet their medical necessity criteria OR (b) your insurance policy under your employer doesn’t cover bariatric procedures (some do not). “A” is workable while “B”is a dead end unfortunately. As you are in HR I realize you know the difference, I just could not personally figure out which situation you were in from the post. ☹️

Edited June 16, 2020 by AlwaysCruising

[chrispat123 11]

It turned out my employers plan specifically excluded the surgery. When I called IBX to check if I had coverage, they said yes. So I wasted a lot of $ in copays and time for a procedure I was not covered for.

I appealed 3 times, lost each time.

Just switched to my husbands insurance. That starts in September. Fingers crossed I don't get screwed again!

[AlwaysCruising 100]

30 minutes ago, chrispat123 said:

It turned out my employers plan specifically excluded the surgery. When I called IBX to check if I had coverage, they said yes. So I wasted a lot of $ in copays and time for a procedure I was not covered for.

I appealed 3 times, lost each time.

Just switched to my husbands insurance. That starts in September. Fingers crossed I don't get screwed again!

Aww 😞 yes, in such cases denials won’t work (I wish they had also told you that). I am so sorry someone gave you bad info early on, it feels rotten to lose time and effort and $! Many policies will now cover it so I hope your husband’s does! And as long as you aren’t a year off from some of the screenings (e.g. the psychological evaluation) they will still be valid (except the 30 day ones like labs).

Edited June 23, 2020 by AlwaysCruising