Appealing Denial

After about 26 days of waiting for a decision from BCBSF I finally received a call from the bariatric surgeons surgical coordinator. My coverage was denied by Blue Cross because they claim it was not a covered benefit. The surgical coordinator stated she was going to appeal the decision. She also mentioned she didn't feel comfortable mailing in the appeals via mail, since that option cannot guarantee the documents were received. I'm holding out hope since my procedure is scheduled the day before Thanksgiving.

Please contact Blue Cross yourself and find out what your policy covers. There is a number on back of your insurance card. There is no use in appealing if it is not a covered benefit.

Initially despite the procedure not being a covered benefit the rep for Blue Cross stated it had to be a medical necessity. So now plan now is to go that route

Get your policy and read it. If your plan does not cover surgery then it does not matter if it is a medical necessity or not. Every plan is different and many employers have dropped coverage for weight loss surgery.

It is like if you caused a car accident and did not carry comprehensive. It would be a necessity to repair the car, but it would still not be covered.

No policy covers weight loss surgery unless the requirements are met. Weight loss surgery is never medically necessary. It is an elective surgery. You need to have a plan that covers it and you need to meet the requirements for your plan.

my cordinator told me most if the time insurance companies denied the first claim for wls. I have Cigna and my process of was super long. I had a group of 10 support group classes, 6 mo of monitor weight loss with my primary dr, group exercise, tons of labs, tests, ekg, and stress tests. I passed everything but was originally denied don't give up, I had to appeal and was approved. I had my surgery yesterday. also my surgeon put me on a strict broth, protein shake and water diet for 2 weeks nothing else not even sf jello. he said that he was going to run tests day of b4 the surgery which could tell if u cheated on the diet. if I cheated I would not get surgery. I passed my test had my sleeve along with other things done, spent 1 day recover and I'm already home.

good luck.

I'm glad to hear that you're recovering and get to a speedy recovery. Thanks for sharing your journey about the appeal process. I'm actually thinking about hiring a well known obesity lawyer to get the decision overturned. Knowing that you didn't give up gives me up.

My BCBS did not cover the surgery, and if I went ahead and paid for it myself and had complications, BCBS would not pay for any assistance or doctor visits either. If it is a covered surgery and you were denied, write down all of the diets and results that you tried to show you can't do it without the surgery. It will help your case to know that you tried different things and it didn't help. Good luck!

Thanks Minkey. Did you appeal the denial?. I have done the supervised diets and my Bmi is well over the requirements with co-morbidities. My visits with my bariatric surgeon were covered at 100%.

My BSBS had an exclusion on our policy. My case worker said that we could try to appeal it, but that it would more than likely be rejected. I decided to go self-pay rather than run the gauntlet of tests and trials that I may have done if insurance had approved surgery. I'm sorry they denied your sleeve, but definitely have a backup plan if you want to keep your surgery date.