Denied -- But Why???

I called Care Allies, Medical Mutual's medical management, this morning and was on hold for 20 minutes only to find out that I have been denied.

However, after talking with two people, including a nurse, neither of them can tell me why I was denied.  At first they started telling me that my BMI had to be 35 with co-morbidity -- I told them it was over 50.  They looked through the paperwork and found that.  Then they said about diabetes, hypertension -- have that I told them.  Then they asked if I was on dr supervised diet -- did that.  How about prior weight loss attempts -- yes.  Both of them then said they really didn't see anything as to why I was denied, but I should contact my doctor to find out. There's no way I am going to let this one go.  Both of the ladies at Care Allies told me I could appeal -- NO KIDDING!!!

Good luck, winnergirl.  I am having a heck of a time with my insurance company, too.  Boy, I hate insurance companies.  I was originally told they hadn't received my info, now they say they have "22 days to reply".  The surgery is scheduled for next Monday, but the insurance company is dragging their (below their belts), 22 days is next Wednsday.  What a game.  I hate this.  Tell us how yours turns out.

Susan, Thanks!  I will keep everyone posted as soon as I find anything out. I think that the insurance companies use these tactics to "test" us. Years ago, while working in retail, I was at a seminar about sales.  The speaker said, "When someone wants to give you money -- you take it.  You don't say, "Well....let me see if that sample is for display, or let me see if we can take your check."  But he also added that the only stores that can do that are grocery stores because you usually need that bread and milk that you went in there for.  So because of this they can be like -- Hey, look!  My line goes down to the candy section.  Well, mine goes down to the meat section.  Let's see if we can get their ice cream to melt and make a mess by the time they get up here! I think the insurance companies are kind of like that. Good luck with your surgery approval.

Susan, I totally agree about the insurance companies wanting us to give up.  Hey, if they say "NO" the first time and 85% of the folks say forget about it, they have just saved themselves a ton of money. I was denied the first time for lack of a 3 month physician supervised weight loss plan.  I started the diet, but also sent an appeal letter.  They sent one back saying that once I finished the three months, the surgery would be medically necessary.  Now I am counting down the three months-only one more to go! I wish you the best of luck, Lisa

From what you have explained, it does not look like the insurance company is attempting to "stall you out". It looks as if you spoke with rather uninformed people (even the nurse!) at the insurance company. Admittedly, there are some trifling insurance companies among us, but most of them do not set out to deny people all day, every day. Most insurance plans that we subscribe to are provided through our employers, which means that the employers set the rules. Above all though, the name of the game for the employer is cost containment. If they can keep down the costs as much as possible, insurance can remain affordable for everyone. In some cases, that means some services that are much needed end up being denied because employers simply don't want to have to pay more money for the next level of coverage for their employees.

If insurance is provided through an individual policy, the best bet is to read the policy fully before subscribing to it because coverage will be based on what you choose.

I am sorry that you are going through issues with your insurance companies. By all means, appeal their decision. If they cannot provide you a definitive answer as to why you were denied, then you have a right to find out, so you can know how to overcome the denial.

I just went thru this with y insurance company. I took the denial letter and went point by point and found the documentation in both the stuff I had already sent and got new documentation as well to prove that I met the requirements for the surgery and it worked I got the letter today when I got home from work saying that they were reversing the decision. Don't give up! Get everything in writing and then very systematically prove that they are wrong. I wish you luck. I know how hard and frustrating this is.