Insurance denial?? I'm confused ! I need a peace of mind!

Hey guys ! Please read all and be patient with me (:

So, I'm in the process of getting VSG and I'm so close . I met with my surgeon months ago and he gave me papers of what I needed to get approved. It was pretty much straight to the point and clear and he's been over it with me . This is what I needed :

• 3 month nutritionist
• BMI 40+ (which I have)
• 1 psych evaluation
• upper endoscopy
• Letter of necessity from my primary doctor .

So, I called my primary doctors office and the secretary's gave me a referral to my nutritionist as well as my surgeon. I finished everything except the psych evaluation which I have to go to in 3 days .

The problem? TODAY. I visit my primary doctor to get my necessity letter from him and he said "I don't think they're going to approve you because you haven't followed 12 weeks diet from me " and I replied "I've already done 12 weeks from my nutritionist. My surgeon told me that's the diet plan I needed to do for bariatric surgery" and his reply was "but , not from here . I'll write the letter anyway and if you get denied then you get denied . " and walked out . IM CONFUSED. The surgeons list of requirements was very clear on what I needed and all he asked from me what a letter of necessity from my primary doctor and nothing else . My primary doctor's nurses are *****ferred me to that nutritionist as well as my surgeon..... WAS THERE ANOTHER DIET PLAN I HAD TO FOLLOW WITH MY DOCTOR THAT I DIDNT KNOW ABOUT ?? My insurance didn't require previous weight history or anything in depth that involved my primary doctor .. Just the letter ( from what I was told by the surgeon) .

- My surgeon made it very clear to me that I only needed to get what's on the form he gave me . It's a very clear and basic list. I've even called the office and they saw I've completed everything except the psych ( which is soon) ..

• - The surgeons office is closed for the weekend and I'm going to lose sleep over the fear of being denied ... I've tried explaining to my doctor but , he's very intimating and just kept saying he doesn't think I'll be approved so, I lost hope and I'm devastated. I tried speaking with the nurses at the office and explaining it to them and they've said the same as the Doctor .. Can anybody from an outside standpoint tell me what they think happened ? Opinions ? Thoughts ? Anything ? I need peace of mind until I can call my surgeon after the weekend ):

Thank you in advance .

I think I am not liking your primary doctor too much. Perhaps you should ask to see his letter first before he sends it anywhere. I get the impression he does not approve or is offended he was not acting as your nutritionist. I would also think the surgeons opinion should mean more than your primary care doctor. For more peace of mind, read over your insurance plan. I myself am still scared of denial but I read over the plan and was able to see I qualify.

Best wishes to you.

There are things that the surgeon requires, and there are things that the insurance company requires. It sounds like these are all things the surgeon has required, not insurance.

As long as the surgeon is satisfied that you have filled their requirements, they should submit your paperwork.

There are lots of little bumps in this process. Lots of paperwork, lots of hoops. Don't get too worried. There are lots of hiccups.

So sorry you are going thru this. I about worried myself to death until I got that final letter of approval. My surgeon's office had a special coordinator assigned to each patient that made sure everything on the checklist was taken care of, and I still worried something might go wrong.

Your pcp kind of sounds like a jerk at this point, but that does not mean it won't all work out. Worrying all weekend won't change anything, (easy to say, hard to do I know) try to put it down and distract yourself. It is good you reached out on here for support and understanding.

As long as the insurance company approves your diet having been supervised by the nutritionist and not your pcp, then all should be fine. Take care, sorry I can't really help, but I am sending good thoughts.

Forget about your primary and listen to the surgeon's office. Your primary is NOT the one who has any experience getting surgeries approved so how would he know? I have NEVER heard anyone talk about needing to follow a diet plan with their primary .. sure, some have done that .. but its NOT required.

Also ... its possible you will get denied ... and have to make a few phones calls, jump some hurdles, resubmit and then get approved. But if you qualify for the surgery according to your insurance guidelines you will ultimately get approved for it. They cannot legally deny you because it would be a violation of the contract you have with them, the most they can do is delay for a little bit. The surgeons office will know all about what's needed because they deal with it on a regular basis. Stay calm and listen to them.

My primary was also a jerk about the whole thing, she didn't want to write the letter even though I had a BMI of 49.7 and my lowest BMI in the 5 years previous was 43.9 ... but she didn't want to write a letter of medical benefit (letter of necessity?) My surgeon had to call her directly to get it anything out of her office.

If you haven't already, you need to call the phone number on the back of your insurance card and find out, from your insurance company directly, what your requirements are. I would not recommend trusting your bariatric surgeon or PCP to know what your insurance company requires.

It could be your doctor is referring to insurance requirements (like mine) that require you follow a 'medically supervised' program. Some insurers require you to follow a doctor program and not a nutritionist program, since they are not MDs. He probably doesn't know your exact requirements. As long as he's writing the letter, you should be ok. I know I went to a nutritionist at the hospital for a consult but then found out she wasn't approved by my insurance (BC/BS) so I ended up going to the NP at my surgeons office to meet the pre surgery requirements. Gwen is right, call the insurance company and get it all lined up. If you meet the requirements it should be pretty cut and dry.

I definitely agree with Gwen. The ONLY way to know for sure is to call your insurance company and ask them. The sooner you do, to sooner you can make sure you have all you need.

It doesn't sound like you were denied, yet. I'd call your surgeon's office - or better yet, GO see them face to face. Get a list of EXACTLY what you need. Cross off the items you've done. Get proof of those that are in question. Submit to insurance. Keep records. Do everything via paper and keep receipts.

Odd indeed. Read your insurance policy as it should specify what the requirements are. Doctor may have had a summary only.

Also read my blog for a successful appeal. It was 8 years ago but did the trick. Diane s