Just found out BCBS denied my request for Lap-Band stating it wasn't a medical necessity.

I'm going to call my surgeon in a few minutes to find out more details about it.

I'm really bummed out. :thumbup:

It really sounds like they denied it because there's no letter on file from your doc saying that the surgery is a medical necessity.

I'm sure you'll have good news soon...and if the news isn't wonderful, there are appeals processes.

Let us know.

Junebug, I bet you need to go to your family Dr. and have him write you a letter that the surgery is a medical neccesity or at least that it is medically necessary that you lose weight because of x,y, & z health problems. I spoke to someone at BCBS when I was getting my info together and he told me that they put a lot of emphasis on the physician letter. So I got a letter of support from both my PCP and OBGYN!

hi,

Can somebody help me?My BMI is 42,but my request for LAP-BAND® surgery has been denied i want to get operated as fast as possible but i donot know what the problem is?

Thanks,

Regards,

Kate George

You need to find out what the problem is. You need to call your insurance company and find out *exactly* what their requirements are for approval for the surgery and then see if you meet the requirements and have submitted all the right stuff. I know there is often a lot more that goes into it than simply looking at your BMI and they are usually pretty picky about having every little thing *just so*.

This sounds like what I am going through. BCBS denied me so my surgeon's office went through 1-800-lapband and the obesity law help team. I don't seem to be getting information from anyone, and am totally in the dark, but I'm going to give it a week or two to see if the system works before I decide what I need to do next..

Hello, I work for an insurance company(BCBS IL actually) and see these quite often. I would recommend calling you insurance company and asking exactly what they're looking for. Also, if you go to the Provider section of their website you can probably find the Medical Policy that they're referencing and you can provide that to your surgeon to let them know in detail what is required. If they still deny your surgery after they get the info requested then ask how to appeal the decision. The reason these surgeries get denied so often is because the insurance company has a strict policy that they're adhering to but if it's truly medically necessary for your health and if you stick with it, you can most likely get that approval. The letter you posted doesn't say that you DIDN'T meet any requirements, just that something was missing so I would say your chances are good. As for the two reasons listed, it looks like the first part that says "Not a medical necessity' is just the standard verbage meaning that all requirements not met. It is the second paragraph that gives you the info you need on what was missing. Good luck to you and if you need any help with insurance lingo, let me know and I'll help you decipher things.

Sarah

Hello, I work for an insurance company(BCBS IL actually) and see these quite often. I would recommend calling you insurance company and asking exactly what they're looking for. Also, if you go to the Provider section of their website you can probably find the Medical Policy that they're referencing and you can provide that to your surgeon to let them know in detail what is required. If they still deny your surgery after they get the info requested then ask how to appeal the decision. The reason these surgeries get denied so often is because the insurance company has a strict policy that they're adhering to but if it's truly medically necessary for your health and if you stick with it, you can most likely get that approval. The letter you posted doesn't say that you DIDN'T meet any requirements, just that something was missing so I would say your chances are good. As for the two reasons listed, it looks like the first part that says "Not a medical necessity' is just the standard verbage meaning that all requirements not met. It is the second paragraph that gives you the info you need on what was missing. Good luck to you and if you need any help with insurance lingo, let me know and I'll help you decipher things.

Sarah

Thanks Sara! This is extremely helpful. Like I mentioned they were sending the medical evaluation the afternoon I received the denial letter. I am hoping that this will be settled today. The Medical Director has not had a chance to meet with the Surgeon as of yet.

*Update*

So it seems the Insurance was requiring Medical Clearance from my PCP. I went today and got MC from PCP which consisted of getting a complete physical.

Needless to say, I did not have enough time to mentally prepare for a specific part of my physical.

Glad it's over and I'm almost 100% sure I will get my approval on Monday.

Rock on! Glad things are progressing for you!

Sounds good!

Don't give up! Doctors are usually really helpful in getting all the info to the insurance companies so that they see that it is really medically needed!!!

I also just got a denial from Aetna - not medically neccessary! I followed their guidelines and I have a BMI of 40. What more do they want?!?! My doctor has to have a "peer to peer" with Aetna's Medical Director? I don't have a good feeling about it - but I don't know what to do. I want to do SOMETHING - but it's like my hands are tied.

I am just confused, is it two reasons for the denial:

1. Not a Medical Necessity
   
2. No Medical Evalutation
   

Hi I just wanted to clear up a few things, I am a medical analyst and the reason that they are saying it's not medical necessary is because you didn't have a physical what they are looking for are other illnesses like High Blood Pressure, Diabeties ect. I don't understand why your Dr did not do this to start with. Have your Dr do a complete physical and submit that info with an appeal and it should be covered. Good Luck,,

Hi I just wanted to clear up a few things, I am a medical analyst and the reason that they are saying it's not medical necessary is because you didn't have a physical what they are looking for are other illnesses like High Blood Pressure, Diabeties ect. I don't understand why your Dr did not do this to start with. Have your Dr do a complete physical and submit that info with an appeal and it should be covered. Good Luck,,

You are correct! I went to Doc's on Friday to get a physical.

He sent them the medical clearance documents on Friday and they have not been processed as of yet.

I think I may need to reschedule the surgery. They said it takes 72 hours to review documents marked "STAT".

Just got my approval this morning at 8:30am. Needless to say, I had to reschedule since I wasn't going to proceed without it.

Rescheduled for 11/02/2009.

Good news at least it's approved!

Hey Congrats! Good luck next week. I'm glad they were able to reschedule you so soon!