question for gary

i read the post you made re: wait or appeal with interest, since i was denied yesterday based on my bmi.  i was denied yesterday, based on my bmi, which they have as 38.6. Apparently when i went for my initial nutrition consult, that is what it came out at. At a subsequent office visit with my pcp, my bmi was at 40, and i provided that info to my surgeon and assume it was included in the application to my insurance. due to the upward trajectory of my weight over the past year, despite my dieting, my bmi is now 40.4. is it possible to reapply under my latest bmi? should i appeal citing the new bmi? i'm not sure what to do, since i clearly meet the criteria now, even if i didn't before. do i start the entire process again or am i completely and irrevocably denied because my bmi wasn't 40 at the time of my initial consult? i appreciate any advice you can give me. thanks in advance. ~Cheryl B.

I am sorry for the issues that you are undergoing regarding your health-insurance company. However, based on the information that you provided, since you were denied for not meeting medical necessity requirements, you and your provider's office should be able to appeal the decision to amend the BMI with your new numbers. Provided that all the other paperwork is in order, the insuranc company should be able to approve you. Please note that adjudication time for appeals can vary between states. Most typically, the insurance is required to adjudicate your appeal within 30 days. To apprise yourself of your rights and responsibilities regarding your medical care, you might want to visit your state's Department of Insurance (or Managed Care) Web site for more information.

My best wishes to you in your being approved for bariatric surgery.

Thank you for this information. They did say if I appealed they would respond within 30 days.

Can I ask who you have for insurance?

i have bc/bs massachusettes.

Sorry, don't know why my response didn't show. When was the initial request?  Were you denied for the BMI reasons?  Or no co-morbs?   A BMI under 40 is usually ok with co-morbs.    If it's been many months since the denial then yYou should have the surgeon re-apply for the surgery.  I just need somemore info

I was denied for BMI under 40, although in the submittal there was my pcp's last office visit showing my bmi at 40. Also, because my hypertension was controlled by only one med, which means it isn't stage one hypertension. However, since then I have also been prescribed a diuretic to control it. The initial request was less than 2 weeks ago. I got the denial last Saturday. Do you think I should wait a few months and re-apply or appeal? Thanks for the response. ~Cheryl

My surgeon called Network Blue New England and spoke to them and they approved me based on his phone call without an official appeal, just 6 days after the denial!