BC/BS GA Denial - need help with appeal... :-(

Help! I just called BC/BS GA and was told that my pre-cert request from Emory Bariatrics was denied... I'm 38, 316, 5'11" BMI: 44.1 with comorbities of sleep apnea and borderline Type 2 diabetes. I filed all the paperwork that BC/BS GA required (weight history, diet history, psych eval, endocrine workup w/TSH, letter of medical necessity, letter of medical clearance, etc)... I was told by my Emory doc (Dr. Lin) that I am a good candidate for the surgery so I am surprised that I was denied. I should receive my denial letter from BC/BS shortly but don't want to wait to start the ball rolling... What should I do? I have an example appeal letter from the Yahoo W.I.N.G.S. support group (from an Aetna member) but would prefer to follow what other BC/BS GA (POS) members have done in their appeal... Thanks!!! -Chris

Hey Cris you need to get that denial and try and talk to someone at bcbs to get the bottom line reason you were denied. I know that bcbs may look at how many co-morbidities you may have. If your diabetes is controlled with diet and if your sleep apnea is not severe or if you don't use a cpap and he does not recommend one for you they may not see that as sever, In that case they will look for your bmi to be over 40 for the last 4 to 5 yrs. This is proven with your wieght and diet history, This is important. NAT

Chris, I am in this with you. I am dealing with this right now as well. My denial came from BCBS saying they haven't received paperwork that I know was included in my original packet. Please get on the phone with BCBS and tell them you need to speak to the Pre-cert group. You need to find out why they denied you. Once you know that you can formulate a plan of attack. If your doctor's office is willing to work with you then you should be able to fix any paperwork snafus. If it's medical info they want, you might have to actually appeal. I would suggest checking into getting a lawyer since BCBS only allows one appeal. The website for the law group most people on this site use is obesitylawyers.com. I am still waiting to hear from Walter Lindstrom, but if I need to retain him I certainly will. My employer isn't going to approve this surgery next year, so this is my last chance! Kelle PS. Please email me if you'd like!

I JUST HAD MY SURGERY ON MARCH 31st. BCBS OF GA. GOT MY INFORMATION ON DEC . 18 , 2003 , ON DEC. 31 THEY SAID I WAS DENIED BECAUSE MY LETTER FORM MY PCP , DIDN'T SAY I WAS SURGICIALLY SOUND. I WENT THAT DAY AND GOT MY PCP TO PUT IT ON THE LETTER. I CALLED EVERYDAY AND MY DOCTOR'S OFFICE THEM ALOT. THEY KEPT SAYING MY PAPERWORK WAS NOT THERE. THEY DID A FRIEND OF MINE LIKE THAT. ANYWAY I FINALLY GOT APPROVED MARCH 10, 2004. SO DON'T GIVE UP , WORRY THEM TO DEATH TILL YOU GET APPROVED !! GOOD LUCK, JUDY

Chris Don't wait....Start !! You need to know why when you already had the tests and the doc says you are a good candidate...Maybe the docs office was not proper in the paperwork that was sent. I do know that when they request something and it is not sent, then the request is Denied immediately.... Good luck and Don't give up!!!! Brenda