Surgery request denied by Anthem

After a tough day, I was excited to find an Anthem envelope in my mail box on the way home....excited enough to open it before I got home. I had only been in Dr. Clough's office on the 12th. Could I possibly have an answer already?!? I was very shocked to read: "....requires documentation to support the member's psychiatric profile is such that the member is able to understand, tolerate, and comply with all phases of care and is committed to long-term follow-up requirements. The documentation did not meet the required criteria. Therefore, this request cannot be approved." I was very upset. My hands shook and my heart started beating real fast. I got out of there and went home to calm down. Once I relaxed a bit, I left a message on Lynn's phone asking for help pulling out the "big insurance appeal guns" and asked that she call me tomorow. I will also call Dr. Clough's and Dr. Prescott's offices, as well....after I hear from Lynn. Her advice will help mold my actions. I wondered if something was forgotten with the submission, because Dr, Prescott commented specifically on my preparation, understanding and readiness and that I was a good candidate. This won't be over until the weight challenged person sings! I'm down...but I'm not out. Anyone else had this happen? Kent

Please try not to worry, it sounds like something was left out or maybe even misplaced at the insurance company. Either way Lynn will help you figure out what is going on, that woman is Amazing!!! I am sure all will work out, I honestly do not think they would have submitted it if they felt there would be any problem Good luck, keep your chin up! Theresa

Hi Kent, It sounds like the Psych Eval was missing from you package. Contact you doctor/surgeon and have them resubmit the paperwork. They have probably received a copy of the same letter you have. Don't get frustrated, mine was denied because the medical coding was not recognized. As soon as a description of the surgery was provided, I was approved. Best of Luck & keep us posted. Cindy K.

Hey Cuz Don't give up and don't give in. I have heard of some folks submitting 3-4 times to get approved. Nag, Nag, Nag um to death. I'll keep you in my prayers. Ron

Thanks for the supportive words, everyone. I've calmed down after thinking it through and agree that something must have been left out of the package. I'm not one to give up when I believe in something. I'll keep you posted. Thanks so much again. Time for some sleep. Kent

Hi Kent, I completley understand how you feel. I have been denied 2x by Cigna though I meet all the requirments. I am not waiting for a thrid denial/approval. This time I fighting back though and writing a letter to the Maine Insurance Commisioner. Don't give up. I agree with eveyone else, something probably got misplaced. I know with CIGNA they are contstantly losing the faxes that my PCP and surgeon send over. While I am not with Dr. Clough's team anymore, I had been involved in their program about a year and a half ago and had a lot of dealings with Lynn. She was TERRIFIC, very supportive and understanding. Good Luck, I know how devistating it is to get those letters. I look at my daughter and just pray that soon I will be able to keep up with her and be the kind of mother I was meant to be. You hang in there, don't give up and NAG, NAG, NAG is exactly what to do!! My email is always open! Samantha Moore [email protected]

Kent, Hey you! So sorry to hear about your snag in the road. I'm sure it will be cleared up. Sounds like insurance companies are just a big pain in the ass. Especially is Prescott specifically indicated your preparedness... Hope to see you soon. Hugs, Casey

Hi Kent, I think it must be something missing. I had approval within a week from Anthem. They have been great to work with so far - I'm 17 day's post op. Keep your spirits high. Teresa