WLS DENIED!

Hi all, yesterday I recieved a letter from the ins. I was denied for WLS.  This is the 3rd time I am denied.  I don't know what to do.  Please help!  I have BC/BS of IL PPO. Thanks.

Appeal, appeal appeal.  Your surgeon's office should do this automatically.  Call BCBS and I do mean BS, and get precise, exact resons for the denial and work to fix them.  It took me 18 months and 8 days to get approved-I jumped through many hoops, but I wore them down.  You can too. Good luck and DON'T GIVE UP!!!!!!  Hugs-Janet K

What was the reason for denial? Did you fulfill their requirements? Is there an exclusion?

What has been the reason each of the three times? BCBS has to tell you why. If you have fulfilled all the requirements that they are asking for and your doctor has submitted the info sometimes the insurance company is too lazy to look for it. It might just be a matter of a small bit of info. Climb down their throats in a nice way and get to the bottom of why you have been denied. Just remember honey draws flys faster than vinegar so be sickenly sweet to them. Get each and every person's name and if possible their personal phone extension for follow up reasons in the future, document exactly what you talk about on the phone with them and the date (s) and time (s).

Chris

Hang in there, all is not lost.  As everyone else has said, they have to tell you the reason for denial, then you just need to satisfy that particular requirement.

Your surgeon's office should help with this.  BCBS of IL PPO is VERY strict about their requirements.  It took me almost 2 years total to get approved, and I took my first insurance company to the Attorney General's office.  With BCBS, it took almost 10 months.

Do not give up.  Let us know their reason(s) for denial, and we can help you better attack that particular problem.

Hi Dawn, thank you for the reply.  Supposedly I need a 5yr. history of being MO.  I have EVERYTHING, what else do they want?  Sorry I am so upset.

OK...........Do you have your medical records for the past 5 years?
Were they turned in with your pre-approval request?
Do they show a BMI of 40 or over for those years?

That is where to start.  Make sure that all those things are in place.
If you HAVE sent this to BCBS, you will have to call them and point these records out to them.  Do you have a copy of what was sent?  Point out to them which page numbers have the information that they are seeking.  Believe it or not, many times they don't read the whole file and just throw this stuff up hoping that you will go away.

If you do not have records for 5 years showing a BMI of 40 for all of those years, how far back do you have these?

This is where to start, and also, Kim M had the same problem with BCBS, and I THINK that she was just shy of the 5 years, but she got them to approve it.  Maybe PM her and ask her how she did it.

Hang in there.....I KNOW how frustrated and angry you are right now........

Your PPC should be able to give you the 5 yr MOB each time you went to him or her they should have weighed you. I got a letter from my PPC that stated I had tried numerous diets for over 10 yrs. I also sent in a note to the insurance with some records and a statment why I needed this surgery! My daughters sent one too! I have BCBS / Iowa

Thanks for your reply, what I think I am going to do is go see another surgeon.  Maybe by changeing Dr. will help.  Because I have everything done.  Take Care.

I have BCBS of Illinois PPO and I was told by my PP and Surgeon's office they are pretty rigid for approvals. However, I contacted BCBS to get all the requirements prior to starting my journey. At my first initial call the representative told me to make sure all requirements were met due to the possiblity of denials.

As for the 5 year history, your primary provider should be able to provide that information.  My PP submitted a letter documenting my weight, weight related issues, etc. The latter was a concern of the PP since I did not have any of 'normal' weight related issues. Like high blood pressure, arthiritis, sleep apnea, diabetes, etc.