I dont know what to do....

I called this morning to check my status and the cs guy told me I was denied and I wasn't medically necessary  . Then I called and told Dr.Olsens office the news and they are going to set up a peer to peer meeting with Dr.Olsen so he could try to change there minds. I called back Tenn Care to find out more of why I was turned down and the 2nd guy I talked to was gone forever before he came back and said it was still pending. I asked why the other one said I was denied and he said he spoke prematurely the decision was still not made. But he had to read it somewhere, that I was denied. Oh I am going crazy (no actually I am there) I have cried all morning, AND THINKING STRONGLY ABOUT GOING TO MY DOCTOR AND GETTING SOME NERVE PILLS!!!!!!

I'm sorry to hear that you are frustrated.  Yes I remember that frustration as well...  hopefully the peer to peer will work...  if not, you can find out exactly why they are denying and handle it from there... but also, start looking around for examples of appeal letters.  I am not sure who on the board filed an appeal, and won, but someone has an example appeal letter....  Hopefully they will see this and give you a link...  but gear up for that letter just in case you have to do one....  We will cross our fingers and pray that you won't have to get that far... 

Take a few breaths... Breathe in, breathe out....  that's it.  Again... breathe in, breathe out.

 Thank you  

I'm sorry, Sonya. I just don't understand why they are putting you through this. The whole process was so painless for me. I never even called TennCare at all. I got all my information and news of my approval from my surgeon's office. They stayed in constant contact with me.

If it does turn out to be a denial, press them for exactly what the denial was based on. Get details so you will be armed for the appeal. Whatever happens, I wish you the best of luck.

Karen

Thank You I will.....I dont know why they are doing this to me either. From what I hear they  took a look at it on the 9th of March and on the last day took a second look and denied me never really went over it. They dropped the ball on helping me I understand that they are busy but everyone needs there fair chance to get reviewed and that just didnt happen for me...

Sonya--I am so sorry...I was denied the first time (private insurance...BCBS) and it was so frustrating, but you can't let them get you down...just keep plodding ahead. You will win this if you stay focused and keep your wits about you.  It's a game with the insurance companies...for them it's about holding on to their pennies and for us it is a matter of life (or quality of life) or death.  The most frustrating part is the not-knowing and waiting, for sure.  I just posted a response to another TN OHers insurance question & I am going to copy it in this post to you...it has information in it that will be helpful to you IF you were denied & if you have to appeal.  Let me tell you though, I had the exact OPPOSITE happen to me...after submitting my first pre-approval packet to BCBS, I got a call about 7 days letter from a nurse who was calling to tell me that I was approved for surgery & wanted to go through pre-admission information, even NUT information, etc...she had a friend who had the surgery & she was going to be my "liason" from BCBS...I was in tears when she called to tell me I had been approved.....oh, wait, I listened to her story about how her friend had done so wonderfully & how healthy she was for 45 minutes...then she stopped short.....she paused and said, "Oh, actually, let me see...I am wrong.....I had two stacks of letters here....a stack of approvals & a stack of denials....you are in the denial stack....I should have looked closer...you were actually denied, I am going to have to transfer you".  No apology. Nothing..I was so so so upset...I couldn't believe it!  So, that sucked, but you know what, I am sitting here 16 days post-op & you will be too...don't worry.

Here's the insurance info in response to the other person's post:

Do Insurance Companies Lie?  Absolutely. Continually. Without reservation.  They are one of the largest for-profit businesses and that profit doesn't come from paying claims or approving surgeries.  I compare them to casinos.....having been born/raised in Reno I always tell people "The Casinos weren't able to build those amazing buildings by paying out money....so your chances of winning are minimal."

That said, I had to appeal my BCBS claim b/c they said I didn't have 6 months worth of s'vised PCP/NUT/Xrcize.  I successfully appeal'd the claim myself, but I was relentless in my efforts and my suggestion is that you take this very seriously, of course, and spell it out for them.  What you are doing, really, is creating evidence in case a civil claim has to be filed.  Sit down at your computer.  Chart out your weights from each piece of medical documentation you have been provided:

January 2005 = Weight/BMI, February 2005 = Weight/BMI, etc., etc.  Of course, you won't have each and every month documented but try to get something from each quarter of the year and as many months as you can.  Do a separate "chart" for each year. 

You want to show where your weight/BMI has been 35+ (if that is the requirement in your Plan Summary.  By that I mean, get a copy of the specific requirements from your policy. Verify that it says BMI must be 35+ for past 5 years and documented in the medical record.) for five years--make it clear and concise.  I am so happy you have found an insurance liason at Vandy (Cynthia) who is helpful.  But you are your own best friend when it comes to advocating for yourself in this process.

Remember, every letter you send to them is part of the puzzle that your attorney will use (if it gets to that) as evidentiary documentation to prove your case!  So, give her/him a lot to work with!! :). 

I am hopeful you will win this on appeal, but, realistically, until the insurance company knows that you are not going to lay down and let them walk all over you they will do all they can to deny each and every claim.  They have entire buildings full of staff whose job it is to find any reason to deny a claim--and sometimes w/out any reason at all.

If you need help writing your appeals letter, let me know--I am happy to review your draft and, if you can email me copies of your attachments, look at those, too when you feel you are ready to submit. 

As far as the "peer to peer"--that is typically the first step after the initial denial.  It is when your surgeon speaks directly with a Cigna hired surgeon to advocate on your behalf. They can be sucessful.  In my case, BCBS still denied my claim. 

What is important is that you find out how long you have from the first denial letter to submit it for appeal. DO NOT LET YOUR INSURANCE COMPANY DO AN AUTOMATIC APPEAL WITHOUT YOU INSTRUCTING THEM TO APPEAL IT BECAUSE YOU WILL NOT HAVE THE BENEFIT OF SUBMITTING THE ADDITIONAL DOCUMENTATION/EVIDENCE OF YOUR COMPLIANCE with the policy terms.  And you only get so many appeals, especially at an in-house level. It will go quicker the sooner you get your approval

You will have a certain number of days to appeal...make a note of that, build your evidence and hit them with an appeal they can't in good conscience (that is, if those running insurance companies had a conscience!!) deny---or, should I say, they won't deny because they know the cost of legal defense will outweigh the cost of surgery.

Good luck!!!! You can do this! xo, Micheala.

Oh my that sounds like me they told me I was approved for the surgery, then told me it was a mistake I was only approved for my doctor  visits.....I was crushed... But yours is bad I would have cried all day long that is what I did today because I was denied. They told me at Dr.Olsens office that Dr.Olsen would  schedule a peer to peer meeting with TennCare and told me not to worry that he usually gets them to change their mind. But my luck I bet that they wont change their mind. Thanks for all the advice. Did they do a peer to peer  meeting for you when you was denied? Again Thanks for the advice it is greatly appreciated.

I would like to share the story about a lady I met in a program.  She is employed at the same place as me.  She got denied from our insurance cause they said that she had lost 100 lbs on her own in previous years, and that they felt she could do it on her own... She met all the criteria under their rules.  It did not say anything on the policy plan about if you had lost weight on your own; I told her that she should fight it all the way.  They even had a peer to peer with the doctor.  Still, denied.

It took her a year before she finally got approved.  But please, try everything you can cause no one is going to fight for you like you will....  sometimes you have to dig pretty deep down inside to find the strength and courage to keep on going.  And, yes there is still that chance that you could get the final stamp of denial...  but you will spend your life always wondering... "what if I had fought for it?"  

I wish you all the success in the world, that you are able to get your surgery approved...  

Thanks Im going to have test run on me about sleep apnea. I do have a mild case of it. That should help because I dont even have that down in my medical records. They are going to call me back today with my appointment. Thanks for all of your help and encouragment.

Sonya,
Sorry to hear that your approval isn't going as planned, but I'm praying that maybe the first guy did just misread something and it's still pending.  Have you talked to Heather and asked her to get involved? I hope that if you have to go the peer to peer route that all will end with a positive outcome.  Take care and you are in my thoughts and prayers.

Regina