BCBS-CA Denial Update

Just wanted to let everyone know that my appeal was approved.  All I had to do was call and tell them they were wrong and ask for them to look it over again.  I know that is simplistic, but that's all that the process involved.  They originally denied me because my BMI is "only" 39 and they did not read the comorbids that the doc submitted.  When I called, they accepted the phone call as an appeal of sorts, and re-reviewed the information they already had.  The ONLY thing new I did was to tell them that with the difference in my height with and without shoes (the doc always measured me WITH my shoes), it pushed my BMI past 40, but they didn't even need to re-verify that with the doc's office as the comorbids (hypertension, hypercholesteremia, joint pain, shortness of breath) were within BCBS's guidelines.   So, if your submission is denied, make sure that they even read the documentation... lol   I now have a date of NEXT FRIDAY (and when I say it out loud I put that emphasis on it too--I'm so shocked at getting in so soon... lol).  Good luck to all of you--I am sorry if this doesn't help some of you.  When I was waiting for the appeal to be reviewed, I read each and every post about BCBS I could find.  But remember, each state has a different BCBS "chapter" and what worked for me doesn't necessarily translate into every state policy.  For instance, I know that most BCBS chapters require a 6-month or more documented diet, but mine didn't.  Mine only required a rundown of all diet's I'd tried, so we sent in just my own summary of diets and the 3-month dietitian supervised diet that the doc requires.  Lisha

You are so correct.  Also, my experience proves that you really do have to stick to your guns and assert yourself at your medical facility.  While we do need to have confidence in our physicians (and if you don't, seek new ones!), you still have to remember that they are human, as are their staff.   Paul, I've seen you say on here multiple times to take active part in the insurance process, and I cannot agree more.  The insurance contact at my clinic was practically no help at all, beyond the fact that she did submit the packet that my doctor's team gave her.  However, she had no real desire to truly be a liasion between myself and my insurances.  She was very rude when I would push for details (for instance, when we started the process, I asked her to contact my insurances to make sure of the requirements on the Clinic's end, and she first kept telling me that normally they require at least 6 months of supervised dieting and a few other things--I insisted that she contact them, however, in case they would require more or less than what she "expected" and what they were telling me on the phone).  When it was denied, she did not help at all either, hence my own phone call to BCBS and the subsequent appeal process.  However, she did not help at all.  I appealed it on my own and followed through on my own.  ALSO--remember that they are not always just being a huzzy in thier unhelpfulness.  Sometimes they have just simply not experienced what you expect them to have had knowledge about.  So be assertive and polite while trying to complete the process.   The team is sometimes so spread out across the medical facility (my own team is at the home location of Marshfield Clinic, a HUGE system with all specialities available) that it is quite possible for the right hand not to know much about the left hand's action.  I did not inform the bariatric team coordinator of teh problems I was having in insurance until AFTER my appeals and during my wait on that.  She was immediately taking action to make sure that the insurance department knew the importance and particular considerations about bariatric surgery.  Should she have known about it before?  Sure--that would have been great.  But she also has probably a million other things to take care of in the course of a day and until one of the patients informed her of any problems, she didn't know more than the insurance department had been reporting to her--who may not have even known about the problems if the patients did not follow up. Lisha

Congratulations on the approval! How did you get a date so quickly? I have been calling they say that the Dr's schedule looks pretty open but for some reason wont let me speak to the person in scheduling. What did you do different?

Cindy--We have different doctors.  :)  Good luck!  I'm sure you'll hear back soon.   LIsha

i know your post is more than a month old, but i was looking for some help/hope because i was denied on Saturday by network blue new england. the denied me because when i visited my nutritionist in november my bmi was 38.6. however, submitted along with that info was my most recent doctors appointment at which my bmi was 40. due to the upward trajectory of my weight over the past year, it is now 40.4.  i am hoping that i can appeal just with an amended weight from my doctors office. your post gives me hope that i will be approved as well. my insurance is also part of bc/bs. thank you for writing about your experience. i have less anxiety right now than i have had all weekend. : * ~cheryl