Denied, ugh.

I've been lurking a long long time, but I've never posted before... I just needed to vent a little about this!

I got a letter today saying my surgery was denied by my insurance. I have a BMI of 51 and hypertension. I'm currently on 2 different hypertension meds and my blood pressure still isn't under control (it's lower, but still in the hypertensive range). I was on 3, but the 3rd was causing photosensitivity, so I'm back down to only 2. My letter says I was denied because I don't have sleep apnea, poorly controlled diabetes, poorly controlled hypertension or a heart condition related to being overweight. It also says "Your health plan will cover weight loss surgery for one of these conditions with a BMI over 35."

My guess is someone wasn't paying attention and missed the whole hypertension thing. I called my surgeons office and they read back to me from the 48 pages they sent to insurance exactly where my PCP talked about my poorly controlled hypertension.

So I called the insurance member advocate people and the person I spoke to said exactly that -- they probably missed it. I'm glad I went through all the testing and months of diet and doctors appointments and my husband taking off work to watch our kids so I could make it to these appointments and classes and tests, etc. for them to not even look at all the paperwork (I know, it's how they work, but STILL!).

The member advocate I spoke to is looking into my paperwork to see if it was missed and is having the nurse look it over again and from there I'll file an appeal.

I'm so sorry Becky.  It's one of those wonderful hurdles that we shouldn't have to go through but unfortunately we do :(    I'm sure they will straighten things out, it will just take time and patience on your part.  I received denials for my surgery when they were just asking for approval for a psych eval :)  Then they approved the wrong surgery.  It happens.  Keep the faith, it's worth whatever you have to go through to get it.

May I ask you what BP med cause photosensitivity?  I have been photosensitive for years and have just assumed it was my eyes.  

me

Hi, it's not an eye thing, it's a rash I'd get from sunlight. It was from hydrochlorothyazide. Everytime I'd go in the sun I'd break out in an itchy rash all over. It would go away about 30-60 minutes after I got out of the sun.

Comment pulled because OH refuses to respect members privacy and moderates unfairly.

Are you sure you don't have sleep apnea? I didn't think I had it so just imagine my surprise when I was diagnosed with severe obstructive sleep apnea. Ask your PCP or surgeon to refer you to a sleep study if you haven't already had one. Sleep apnea seems to be the magic words to get quick approval from insurance.

I have an appointment with my PCP on Monday. I'll ask him for a refferal then. Thanks for the suggestion. I'm pretty sure I don't, but like you, I could have it and not know it.

Do you snore? That would be a dead giveaway. I live alone and I had no idea I snored. I swore I didn't. The sleep tech disagreed and I'll just leave it at that...

I don't usually. I have on occasion. My husband liked to joke about it when I was pregnant and snored, so I imagine he'd be happy to tell me all about my snoring if I did it now. I have woken up with a gasping feeling a couple of times though.

And that would be the other tell-tale sign. I too wake up from that gasping feeling but I didn't think anything of it.  I'd bet the ranch (If I actually had a ranch) that you have apnea. THAT will get you approved. It is worth it to find out if you have it. Sleep studies aren't bad. Honest.

The insurance companies have an automatic denial response now, so don't fret too much.  If they come back and deny again the fact that they admitted they did not review the file first will help you on appeal.