BCBS Denied me!
I am in shock right now. I have to admit I was not prepared for this possibility. I never expected to be denied. They said the surgery was not medically necessary. I weigh 453 pounds, I have high blood pressure and type 2 diabetes. I don't understand what they want from me.
Can someone please offer any insite? I was expecting approval based on the experiences I've read here. BCBS is supposed to be easy right? The worse part is Dr. Appel's office has already told me they would not help me appeal if I was denied. Is that standard procedure for the surgeon's office?
The letter detailing exactly why I was denied is being sent to the surgeon. I've left a voicemail asking to be notified as soon as it arrives.
What in the hell do I do now?
Kelle
I got the info from BCBS. I haven't heard from the Drs office yet. The letter of denial went to the surgeon's office so I don't know what the problem is yet. I also found out that I only get 1 appeal with BCBS. I couldn't believe that. I made an appt with my PCP this afternoon to let him know about this and see if he'll modify his letter for me to state that this surgery is medically necessary for me. I'm not sure if he will or not. That could make a difference. I'll let you guys know what I find out. Right now I just want to crawl into a hole somewhere. I never expected this.
Kelle
Fight it!!! I also have BCBS (of Ill)PPo. I don't know what the POS plan is that you have. I was approved pretty easily but that was in may of last year. I think the insurance co are just trying to make it more difficult. Maybe they need some additional stuff which wasn't sent??? I wish you luck. It seems as though your surgeon is willing to help you out--which is nice. I think a lot people have trouble with DR offices helping with insurance so at least you have something positive from this. Hopefully, it won't be too long with the appeal. Kinda weird -- Appel as your DR so close to appeal--it's in the bag!!!
I am with BCBS of GA, POS plan. I work for Bellsouth which is a GA based company and we do our own insurance as far as I know.
The crappy thing is Dr Appel's office IS NOT willing to help me file my appeal. At least that's what they told me in the beginning. Because I didn't submit the 6 month supervised weight lose plan (which BCBS doesn't require) they told me they wouldn't help if I was turned down. Now I don't know if they meant if I was denied because of the missing diet info or just denied in general. I'm still waiting to hear from Dr. Appel's office. I know I had everything BCBS required. My only concern is that maybe my PCP letter was worded incorrectly. He stated I was medically cleared, but not that this was medically necessary for me. But hey, the instructions for what the letter needed to say came from Dr. Appel's office!
I'm trying not to be too upset and just be patient. No sense in being all doom and gloom until I know what I'm up against. Thanks so much guys!
Kelle
Dear Kelle,
Do not give up! I also work for bls and have bcbs pos. I was denied the 1st time but Dr C. Daniel Smiths ofc sent in the appeal and I was approved the 2nd time. It was the length of the bypass that I was denied as investigational but Dr Smiths ofc quickly got an appeal going and I was approved. I cant believe a Dr's ofc wouldnt help you with an appeal. I would let them know I didnt appreciate them not fighting for me.
Do they just want to operate on people that are easy to get approved. I would tell them just that. It sounds like all they want is money not to help people that truly need it. If they won't help you then change Dr's.
MUST HAVE!!!!!!!
1) Letter of Medical Necessity
2) Letter of Medical Clearance
3) Phyc Eval
4) Nutritionist Eval
5) Blood workup including TSH(important)
6) 3 yr diet history
7) 10 yr weight history
*If you have no co-morbidities then you have to have a BMI of 40 or more for 5 yrs or more also...........!!! This is a must have and if your missing 1 little item or if your clearance letter does not have "Kelle is Medically Cleared for Bariatric Surgery" written to the tee from your physician girl they will deny you. There are 6 people on my floor alone that had the surgery and 10 more in the building that I know and that is just people I know. Bellsouth is certianly paying, it's the documentation. So your PCP has to be Bariatric friendly to be willing to write these tedious Letter without flaw. I had to type my own letter and have them redo it on letter head and have my pcp sign it. Girl what she wrote was a joke. But it included my height wieght bmi how long bme what diets I tried and failed. What problems I had how this would cure my problems how life quality of life is bad and this will make it good. She also had to say it was medically cleared. On the clearance letter it didn't have to be sooo detailed but It did have to include in the first paragraph on the first line that She said Natalie is Medically Cleared for bariatric surgery. I don't belive in playing with these people...!!!
NAT
CALL ME
Hi Kelle,
I would call back BCBS and reverify the information you were given. When I was checking on my approval the csr told me I was denied due to not being medically necessary which was wrong. I asked her to recheck
the reason for the denial because there was no way it was not medically necessary. {I weighed 397 with type 2 diabetes, high blood pressure...} After about 15 minutes she came back and said my pcp letter of medical clearance was not submitted. Once that was sent in I was approved within days. I have BCBS of GA HMO with POS option.
Marie
post op 12/02/03
Dr Hart, lap rny
-72 lbs
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