Just got denied!

Greetings everyone: Received my denial letter today from BCBS of CA PPO plan.  It states that the clinical information provided by Dr. M's office does not support medical necessity as the peer reviewed literature does not support an outcome benefit over standard non surgical treatment in a patient with a BMI from 35-40 without co morbid conditions including but not limited to life threatening cardio pulmonary problems, severe diabetes, cardio vascular disease or hypertension. Ok, I'm fairly educated but really what does the above statement mean?  I know that I am borderline as my BMI is 39 or 37 (depending on if you use my weight in Jan or April), and my co morbidities are not severe enough (per the insurance company nurse review) asthma, high blood pressure and depression.  This make me wonder what was missing.      I have 30 days to appeal.  Has anyone been successful in overturning their denial? Any advice or assistance is  greatly welcomed and appreciated

Were you ever given disability for your condition?  I would think if that happened, there would be an earlier review, preceding the nurse. I would review literature on asthma, and make a case that it is obesity related.  It is quite a serious condition, and it is life threatening.  I am planning to research myself, after reading your letter.  I have fibromyalgia, which is not on the list--but I am on disability for it.   Thanks. Good luck. Jeannie

I would appeal it .  Sometime insurance company turn you down  then you send the appeal in and they approve it. Trying to see if you really need it 

appeal it.  They mean that your BMI isn't over 40 so you need co-morbs.  BUT, you have them.  And high blood pressure is a significant one.

Gary, Here is a question for you... I am 30 years old. 5'0 and weigh 190. My BMI is 37.1. I have PCOS (infertility, irregular cycles), insulin resistance which I take Glucophage for. I also have hyperlipidemia which I take Zocor for. I have an extensive family history of diabetes and heart disease. My father actually passed away at 49 (2005) due to diabetes complications.  I have Cigna POS. Do you think I have a chance? I know that I have to complete a 6 month plan with my PCP before an approval is given. I was just wondering since my BMI isn't 40 what my chances are. Ali

Hi Gary, Thank you replying to my post.  I took your advice and filed my appeal, it was pretty lengthy as I took the time to research and pull all the journal studies to support surgery with the lower BMI plus, additional studies which showed the increased risks with cancer, stroke, high blood pressure for someone of my age and ethnicity.  Plus I provided a very detailed medical history. How much of this helped I dont know but I was approved (yippie!) I think I just needed someone to tell me what to do. Thank you!!