BCBSAL Appeal being reviewed

BCBSAL denied my claim so I filed an appeal about a month ago.  First it was being reviewed internally and now they have sent it to an outside physician to determine medical neccesity.  They hope to have an answer for me by next Friday, which will be more than the 30 days they have to make a determination.  To the best of my knowledge I meet all of their criteria...3 year history of BMI over 40, current BMI over 40 and a six month supervised diet with my PCP.  I also have several minor co-morbids, but none of the major except asthma.   Has anyone had theirs reviewed by an outside physician?  How does that work out?  I am still hoping for an approval this time around.  If not, I will just appeal again.  They never gave me a real reason for denying me in the first place, just that I didn't meet their criteria, which I do. Sandi

I think they have to, by law, tell you the reason for denial.  That way you can send them the proper info (ex: resend your 6 month diet info if they say you didn't comply, etc.).   I wonder what they mean by an outside physician.  Is this still your first level appeal?  With mine, they involved a physician that did not work for their insurance company and wasn't involved with the original denial.  That is a good thing for you.  It didn't help me because I was requesting the DS, which they consider investigational. I don't believe Alabama has an external appeals process, do they?  Hmmm, I would still want that exact reason for denial!!

YAY!  I just got word that I was approved for my surgery!  I can hardly believe that they just called and said it was approved.  I am soooo excited.  So all you others who have been denied and are appealing, just know that there is hope.   Sandi

YAY!!!!!!!!!!!!!!!!

Congrats on having your denial over turned, Do you have a date yet?

Nope, I don't have my date yet.  Even though I got a verbal approval, I have to wait until my surgeon's office gets the approval letter before they will schedule my surgery.  At least I know it's in the works. Sandi

Congrats on your approval Sandi!! I have BCBS AL and got my denial letter on Christmas Eve!  It said I was denied because my BMI hasnt been over 40 for three years but it has.  When my paperwork was submitted it was compiled from 3 different doctors.  Each doctor had a different height.  They used the tallest of 5'5" and that put my BMI in 2003 at 37.9.  I appealed today using my current height of 5'3" so I hope it gets approved.  This whole thing is soooo stressfull.

BCBS is notorious for denying people the first time.  They never really gave me a reason when they denied me but approved me on my appeal.   Stay on top of them and call on a regular basis to let them know you are serious.  I can give you a name and number of someone who was helpful to me while my appeal was being reviewed.  You can never tell how long it will take for an appeal review.  Mine took about 4 agonizing weeks before she called to say I was approved.  Hopefully yours won't take as long.  But definitely call often.  Don't worry about being a pest by calling too much, they were always nice to me when I called.  And always get the name of who you talked to and document the call. Good Luck with your appeal! Sandi