2nd Denial from Highmark

Well, I have been denied a 2nd time by Highmark. I submitted over 40 pages of medical information and citations and they said they still won't cover it based on their stance of "investigation/experimental" and the fact that bypass is the "gold standard" yada, yada, yada. They said they have only covered one other company and that's the Railroad workers. I have no clue what they did but I need to find out. I but they bought a rider for their policy and now it's covered. Now I appeal to my company. We'll see how it goes. I am absolutely not giving up and I'm NOT getting bypass no matter how much these insurance people push me towards it. God, I am just so sick of this never ending battle!!!! It almost feels hopeless but I just have to stick with it. I see folks on here that battle for 1 year or more and finally get what they deserve. So, I'm off to continue the war. Sometimes I think that if i put this much effort into excercising and eating well I wouldn't need this surgery. It just makes you stop and think..ya know. But, I know me and even if I lose 100 lbs, like I've done 2 times before, I will gain it back without restriction. Thanks again everyon for such wonderful support. Gina B.

I know exactly how you feel , I have completed the prep program for Aetna and took all the test and have been denied 2x now up for appeal again. So tired just want to hear I'm approved, Some insurance companies stink. and Aetna is surely at the top. I'll be praying for you that you get an approval, they really put some of us through hell. But guess what the devil is a lie and God is still in controll, all praises and Glory to God,he never left us yet.

I can definitely understand your frustration with insurance companies. It can seem that they care very little about the people who need them. Coming from the vantage point of someone working insurance though, I can tell you that if your coverage is through your employer or the employer of your spouse, the level of difficulty that you will have with the insurance company will be proportionate to how much your employer or your spouse's employer pays for your benefits. I have seen some employers who go "all out" for their employees and purchase nearly every rider possible for their insurance plans. In such a situation, almost anything would be covered with little need for pre-authorizations. But, I have also seen some employers who pay very little and elect only the minimal riders for coverage. Their employees tend to have the most issues with getting procedures authorized, and they tend to pay the most in out-of-pocket costs as well. I agree that God is in control. I feel that He can best be in control when we as His people are as informed and educated about a situation as possible, as admonished in Hosea 4:6. Good luck with your appeal. Your tenacity and knowledge will bring you the results that you surely deserve.

I went through Aetna hell but finally got approved. Why are they telling you? Jim

Aetna is HELL.  I am still working on getting my approval after being denied 3 times, my surgeon is about to do a peer to peer, All I can do is pray now.

Hang in there!  The peer to peer review is the only way BC/BS finally approved me!  I too was being denied because I was my BMI was not  40+ for 5 years.  I had lost 70 pounds back in 2001 then of course gained it all back.  But my surgeon convinced the committee and I had surgery a week later. Jenn Y. banded 11/3/05 Port Replacement Surgery Scheduled for 9/21/06

What are you trying to have lapband or DS? I have Highmark and am trying to have a revision to my RNY and they are refusing to do any revision to the original to RNY unless I can show the problems with it now were from the original procedure and not caused later. Yet, I am still MO and my policy says they treat MO, surgically, and I never lost and regained the weight just have been unable to lose all the weight and have not even lost 50% of excess despite being compliant and can prove I've been compliant. But they also don't cover a revision to DS or banding the pouch...so basically my policy says my MO should be treated but they are refusing to treat my MO...regardless of their policy on revisions.

Sarah: I'm so sorry you are going through Highmark hell.  They really have a lock on this whole denial process. 

I am trying to have lap band.  My policy says straight out that it doesn't cover it. When I itially started this journey I called and asked if they covered a certain CPT code and they said yes.  It was the old code for LapBand.  Then when all my consultations and everything was done, my doctor submitted under the new code (as required) and Highmark denied me.  So, that began the saga that I'm in currently.  It's horrible.  They just won't be reasonable!!!! 

So,you had RNY?  You had issues and need a revision and they won't do it? What reason are they giving you.  That's obscene. 

Do you live in PA?  My Highmark policy is administered from PA.

Well, please let me know how it going for you.  If it means anything, I think you look amazing.  I see a HUGE difference in your pics. Good job so far!!!

Gina Breen

Thanks, I have them with BCBS of Florida. They actually state in my letter that patient successfully lost weight but has regained and I have not...I was 462, now 298, never lower and gained back. Still have a BMI of 51, haven't lost 50% of excess...now I would think that the letter clearly states misinformation then I should have good grounds for appeal...we'll see!!!