does this make sense?!

I called the insurance rep today to find out that I was not approved again (this is the second time) but this time because it is not a covered benefit (yes it is) and that there was not documentation of eighteen months of dr supervised/least restricted attempts ast losing weight. I told her in Indiana its six months and that yes, it is a benefit that's covered. My husband was approved on the same insurance three weeks ago for gastric and going for his testing soon. She said something about my doc calling the doc that reviewed the case at the insurance company for a peer to peer review/conversation. Has anyone heard of that? Does any of this make sense? This is frustrating and disheartening....

I have not heard of anything like that.. is YOUR doc on board with this surgery for you??? That stinks your hubby is covered but you arent.. Appeal.. Linda

i called the patient rep at the doctor's office today and she got the same message from the insurance yesterday. she said that the doc who did the diet supervising is the one that should call the peer to peer doc but the insurance woman said it should be the doc requesting the surgery. so, yet another confused thing for me. i went to the doc's office who did the supervising and of course she was "in with someone" so one of her staff talked to me and told me she's the one that does the talking with the insurance anyway. i told her they said only a physician can call so who knows what will happen. she's suppose to call me tomorrow. my doc really isn't crazy about the idea as she said she had three patients who had it and two had problems. she also said it just "doesnt' work" so who knows what will be said. she does know though that i made up my mind to get it done. i'm hoping it gets through. i still don't understand their belief that i'm not covered though. i called work to confirm that nothing has changed and they said everything is the same! so, thanks for your help!!! i'll keep people posted!!! stacy

Stacy, I have heard of the peer to peer review. It's kinda a step before appealing. Often, the situation can be cleared up with just that phone call. Do have your doc make the call. Sherri

the insurance person and the doctor's insurance rep both said the peer to peer is a short cut to the appeal process and can be cleared up in twenty four hours. i'm hoping something helps. its only getting more confusing! thanks for your help! stacy

My surgeon had to do the peer to peer for me to get my approval... most times it's cleared up with that... it seems to be a pretty common request. Jessyca

i'm hoping it will work. there's so much confusion though its ridiculous. which doc is suppose to call? the insurance says the doc requesting the surgery the doc requesting the surgery's staff is saying the doc who supervised my diet for six months *****ally isn't too crazy about gastric by pass as she doesn't think it works and the patients she has who has had it has had problems. so, who knows. i'm going to find out more tomorrow. i won't let this end...thanks for your help!!! stacy

yeap..not sure what ins you have but they hire not so bright people...the peer to peer use to do nothing but waste time, but now they seem to work....do not give up...keep pushing and appeal appeal.....your in for the fight of your life

Stacy, i never had to do an appeal (I was never denied) but i do know that the insurance company wanted to speak to Dr. Clark before they made their decision. As soon as I hung up from talking to them they called Dr. Clark and within 24 hours I was approved so hang in there. I know easier said than done , Dawn R