HELP Now What

Long story short. In Dec I thought I was approved for surgery. I was told over the phone. Later I find out that more info needed....Last week I received my denial letter. I just contacted the hospital they resubmitted the info again. They are not having me appeal yet. This entire time I was under the impression that my BMI needed to over 40 w/no comorbidities (sp). I have completed everything, including my 6 mo Dr Supervised diet that ended in Dec 2005. I just checked out the website for my insurance, as of Dec 2005 you need the following below! "A BMI of 40 or greater and there is at least one (or more) diagnosed comorbid medical condition(s) that has not responded to appropriate treatment and threatens the recipient's life, or A BMI of between 35 and 39 with documented high-risk, comorbid medical conditions that have not responded to medical management and are a threat to life (e.g., clinically significant obstructive sleep apnea, Pickwickian syndrome, obesity-related cardiomyopathy, coronary heart disease, medically refractory hypertension, or severe diabetes mellitus)" I have NO comorbidities but my BMI is over 40, I think it is 47. What should I do?? I'm so lost. Do I start to write my appeal letter. What for the insurance to deny me a second time, since the hospital has told me not to appeal yet?? Kimmie

Kimmie, If your hospital has said to not appeal yet, then don't! You usually have only so many times that you can appeal a denial. Wait and let the hospital do their thing. It'll work itself out eventually. I know the waiting is soooo difficult. My insurance BCBS/WI jerked me around for months, making me have this test and that test and all these things, which they ended up paying through the nose for. In the meantime its very frustrating and disheartening to you, the patient waiting impatiently for surgery. Keep faith that it'll work itself out. Nancy E.

Thanks Nancy, I checked with the hospital again this afternoon and they told me that the have submitted again with "Medabolic Syndrome" as my comorbidity. She said that it is a pre-diabetic condition and hopes that they will accept it. I then contacted the insurance. They had received the information and have sent it back to the hospital, requesting additional info again. The main reason that I am concerned about the appeal is I only have until March 11th to get it submitted. I know that seems like a long way off. But I want my letter for the appeal to be VERY informative and as detailed as possible. I have already started gathing the information that I will need so when the hospital gives me the go ahead I have everything ready. I don't want to miss my deadline. Kimmie

Kimmie, It sounds like you are on the right track procedure wise. The waiting is the hardest especially when it is out of your control. I found that being on this site confirms that I am not alone and the support keeps me grounded. We are all behind you and are sending good thoughts and prayers. You are worth the wait!!! Lucy

i believe that if they changed their conditions for having the surgery after you began to follow their first conditions, the new ones should not be in effect and they should be made to go with the ones that you were following. BUT LET US ALL HOPE AND PRAY THAT THE HOSPTITAL GETS THRU AND GETS YOU INTO THE OPERATING RM. IN TIME. martyhoth