Denied - need help with appeal

I have BCBS-AL and was recently denied because my BMI dropped below 40 one month during the last three years.  (to be more exact...two years and three months ago).  With the exception of that one month, I have done everything to their requirements, completed my six month supervised diet, current BMI of 43, several minor comorbids but none of the major ones like diabetes or HBP.  I haven't gotten my official letter of denial in the mail yet, just got a verbal "NO" over the phone so I suppose I can't officially appeal until I receive the letter, but I do want to get my ducks lined up and try to prove to these guys that I still need that surgery.  I need to prove that the comormids I have are enough and the one month that my BMI dropped below 40 it was 39.6.  I cannot believe they denied me because of that one month. Any help appreciated. Sandi

I have BCBSIL and I did everything right, they even told me they had everything they needed. The insurance girl at the surgeons office said it looked good, there was nothing missing. Still I got a denial, they said not a low enough calorie diet, as shown by lack of substantial weight loss. The insurance girl has now sent my file to appeal with her letter. It seems there is no reasoning behind some of the decisions the ins co. make. Some people get approved, and some denied. I don't really get it myself. Good Luck!                           Renee

Renee, Do you plan to appeal?  I lost ten pounds on my supervised diet and gained back four.  I guess BCBSAL didn't have an issue with that.  Keep at it.  Hopefully you can appeal and get approved.  I plan to haunt them until they approve me...lol. Sandi

Sandi-- From my understanding, when showing weight history, you only need to show one visit per year.  Do you have another weigh in for that year that you can use?

Yeah, it was submitted.  I can't believe they denied me because I temporarily lost one pound three years ago.  Geez!  I was looking at their BMI chart and it shows that they round up so if that's the case then they should not have said no.  My BMI was still 39.6, which we all know rounds up to 40.  All because of one pound one month.  My surgeon's office said to try again after that month drops off the three year history which would be July/August.  I say APPEAL, APPEAL, APPEAL.  Heck, it was in July 2004 so would that even count as within my 3 years? Sandi

THEY WANT YOU TO GIVE UP! THATS ALL THEY WANT YOU TO ACCEPT A "NO" AND MOVE ON. DONT DO IT. KEEP FIGHTING! ALONG W/RENEE I HAVE BCBSIL AND I HAD TO DETAILED DOC. FROM MY PCP TO GET APPROVED. I FINALLY DID GET APPROVED BUT I KNOW THEY JUST WANT YOU TO GIVE UP. GOOD LUCK AND KEEP GOING -TAMIKA

Go baby sister, GO!!! (really my sister ) Susan

An update of sorts...my appeal is being reviewed right now.  I was supposed to leave early today but now I am waiting to hear back on their determination.   I spoke with a supervisor and explained that their letter did not state why I was not approved only that I didn't meet their criteria and I told her that I had also sent an appeal (which I know was received because I sent it certified).  She said she didn't see my appeal so I faxed all 40 pages to her about 30 minutes ago.  I told her I was baffled because I know I did everything that was required, and if there was something I was missing then I needed to know exactly what so I could fix it.  Soooo, I am waiting for her to call again.  Nervous as usual.  Pray that she reverses the decision and says I am approved.  Edited to add...They said they have up to 30 days to respond....argh.  I will be calling at least once a week to check on it. Sandi

Sandi, I am in similar situation.  I received a verbal denial from the insurance company on Wednesday.  According to the insurance person,  I do not have a BMI of 40 for 5 years.  Yet I know my BMI has been greater that 35 with co-mordities for longer than 5 years.  I was also told to wait on the denial letter but I don't want to loose traction.  I definiately feel your frustration!! slimpeach( or at least trying to be slim)