BCBS Denied

[MC BCBSil 3]

Peer to Peer BCBS also denied. Had appointment with primary care and she formulated letter in support with various reasons that stated I met all the criteria required after the peer to peer now waiting on appeal. I have hear that these tend not to go well. Looks like BCBS will avoid meeting their obligations to subscribers. I am so disappointed. I been forced to wait though out this process 1st 6 months of requirements by the Cleveland Clinic (6/4/2023 - November 29, 2023) to get Denied. Then for peer to peer (December 30, 2023) of which I have received nothing in writing about results. Just a email from Cleveland Clinic saying it was again denied. I let them know I wanted the Appeal that they submitted in January and now I will not have a result for another month 2/17/24. In the mean time still getting fatter went to annual appointment primary care 1/8/2023 and it is official BMI 41.2 with high blood pressure, joint issues and overall just not feeling well. OSU primary care wrote letter supporting me having procedure and yet BCBS still continues to make me wait. I was told decision will be available on a Saturday 2/17/2023 and that too seems a little off to me to make decision available on a Saturday. In mean time I am held hostage to this appeal process. I was told by BCBS I could yet appeal again to another outside agency if I am unhappy with their findings. This sucks and this should not be the health care insurance companies treat not just their insured clients but the hospital that support their plans. This is so out of wack. If somone qualifies for treatment by their provider (my doctors) and through the terms of my health care policy (BCBS) I should not have to go through this mountain of red tape and still yet possible be denied the care in which I pay for every month. This sucks.

[The Greater Fool 1,955]

If they cover the procedure, then aren't they compelled to give the reason(s) for denial? I've often seen simple/stupid reasons for denial that were easily overcome. Even if not simple/stupid it gives a clear target to overcome. But a simple 'Denied' seems like a problem in itself.

Good luck,

Tek

[MC BCBSil 3]

Yes, you would think that is simple and should be but the amount of work and time is the disappointing part. Thanks for the support and feedback. Cleveland Clinic is handling the appeal. Note when doing my search saw where bcbs is in B$ law suite that is class action. Company once had such a good name is find many ways to try to fatten the bottom line and I guess this is one of them. Frustrating and ruining them as reputable and reliable health care company. I have been with them 30 years. So sad.

[ChunkCat 689]

I'm so sorry you are going through this. I would suggest you formally request an explanation of the denial. They have to give it to you in writing far as I know. I would not rely solely on the clinic to deal with appeals for you. It could be something very simple that they are being stubborn about fixing and you are getting caught in the middle. I've had this happen on numerous occasions. Also, peer-to-peer CAN sometimes clear things up and get an approval through. I've had it happen with several expensive procedures they kept denying for stupid reasons... If bariatric surgery is covered in your plan, they have to tell you why they are denying you. I hope you hear good news soon!

[SleeveToBypass2023 1,844]

What kind of BCBS coverage do you have? When I had my initial sleeve surgery (and my revision an year later to bypass due to complications) I had BCBS (the highest Diamond plan) and they approved my initial surgery in 48 hours once it was submitted and 72 hours for my revision once it was submitted. I know some plans don't offer a lot of coverage, or require a thousand hoops to get an approval.

[BigZ 65]

As a BCBS users, I ended up doing self pay and going to Mexico....it was a joke to try and use BCBS.

[BeanitoDiego 125]

I had to reach out to BCBS myself, on two separate occasions, to figure out a claim issue and was able to get it resolved to get surgery covered. I was very strict with everything that I had to do to qualify for surgery in the first place, plus I have the persistence of a hungry mosquito.