Gaining Weight to Qualify for Surgery/Insurance Approval

(deactivated member)
on 11/7/13 3:39 am

Just the nuts and bolts: 

Consulted with a surgeon about having DS on September 18th. 

BMI that day was 49.4. 

BCBS says BMI > 50 is required to cover DS surgery.

Claim for DS was submitted to insurance company (BCBS) in October. Surgeon thought with my comorbities that they would approve it; they didn't. Got the denial letter on 10/31, it says my BMI wasn't high enough. 

Went to the surgeon's office for an updated weight yesterday, and my BMI is currently 50.8. 

I'm not sure what to do with that information. Do I just include it in my appeal letter to BCBS?

Or should the surgeon's office resubmit with this new information? The coordinator at the surgeon's office asked me what she should do, and I don't know what to tell her. 

I definitely don't want to screw this up! Has anyone been in this situation?

LupitaChin
on 11/7/13 12:05 pm
LupitaChin
on 11/7/13 12:08 pm
I am self pay BUT if the reason they gave for rejecting doesn't exist then it is definitely worth a shot!!! Good luck!
Valerie G.
on 11/7/13 8:58 pm - Northwest Mountains, GA

People have done it, and it shouldn't be too hard (probably a day of salty food will bring you over).  I would try calling insurance and ask them if it's possible.  It doesn't hurt to ask.

Valerie
DS 2005

There is room on this earth for all of God's creatures..
next to the mashed potatoes

MsBatt
on 11/8/13 1:26 am

Of, definitely appeal! What state do you live in? I might know some people who can help you fight the insurance company.

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