DENIED. NOT MEDICALLY NECESSARY!?!
I just got off the phone with my insurance company. Long story short, I was DENIED. Why? Because the medical review board deemed it UNNECESSARY.
What health problems do I have from being 260 pounds while 5'2 in height and 18 years young?
*Horrible asthma. Can hardly breathe anymore.
*Body aches. Back and feet pain.
*SEVERE GERD. On a scale of 1 to 10, it's a 10000. I've been taking Nexium for years which in turn has given me dozens of stomach polyps.
*Disability. Can't work or even play with my 10 month old daughter.
*Irregular menstrual cycles. Associated with horrible cramping.
What I'm upset the most about is that when the woman I spoke with from the insurance company told me I had been denied, I had asked her if there was anything I could do to get it approved and she simply said, "Nope. It's medically unnecessary." Pardon my French, but bull****! I can get it appealed, right? Luckily, my mom works in insurance and knows what to do. I tried calling my case manager at the surgeon's office to help me get it appealed but of course she's been off work for a week and won't be bac****il tomorrow.
I'm just scared. Needed to vent. How do I get this thing approved? I'm at my whits end with all of this. I NEED this surgery.):
Anybody else get denied due to not being medically necessary and then appealed with an approval?
All success stories are WELCOME!!!! Please....
I've seen several people win successful appeals. I'm thinking perhaps they weren't made aware of the comorbities that go along with your morbid obesity. Don't trust the surgeon's office to make your case. You have your mom's knowledge - you can make it work for you.
Valerie
DS 2005
There is room on this earth for all of God's creatures..
next to the mashed potatoes
Don't give up. I would speak with your surgeon's office and possibly your regular dr, pick their brains and find out what "magic words" you need to have in your appeal. I say this because a lot of insurance companies have a limit on the number of appeals you an make, so you ned to get all your ducks in a row before you start the appeal process.
Don't give up! It looks like at your height & weight it should be enough to have the surgery. Did you get a sleep study done?, maybe you have sleep apnea, that's a co morbidity that would help in your appeal, but find out specifically why they deem it not a medical necessity when you're considered morbidly obese.
No one surgery is better than the other, what works for one may not work for another.
T-Rebel
Calm down....I work for the biggest insurance company in the USA. I'm a Review Nurse. When you get that statement, all that means, if you truly have a bariatric benefit and you meet the requirements, is that something wasn't turned in. IF YOU HAVE THE BENEFIT AND YOU MEET THE REQURIEMENT... at that point, they would do Peer to Peer...meaning the 2 docs would talk and figure out what else you have to have. That is a general statement that we use when we deny...not medically necessary. AND...the people who pick up the phone and talk to you are non-clinical. I can assure you they don't have access to the screens that will give the information as what exactly is missing. Your doc can find out for you and its a simple fix
The best thing to do is to call your insurance company and speak to the clinical administrator and request in writing by email or fax the entire list of the requirements for WLS under your plan. I was denied at first because the insurance had first given my doctors office one set of requirements but it didn't pertain to the specific medical plan that I was under. I requested in writing the requirements and realized that the only thing missing was to complete a psych evaluation and I was approved with the doctors appeal letter.
WEIGHT: HW: 285 Starting Weight: 277 Surgery Weight: Current: Goal: 170
