Denied
(deactivated member)
on 10/16/08 11:48 pm - Woodbridge, VA
on 10/16/08 11:48 pm - Woodbridge, VA
What was the reason for denial? I have a BCBS PPO, but they are all different. I have Horizon Direct Access BCBS of NJ PPO--what is yours?
What surgery are you trying to have? BCBS rarely denies RNY's. I know they don't like to approve lap band for BMI's over 50. I have BCBS state of NC PPO, I was told they would only pay for RNY. I am going for the sleeve...waiting for my denial LOL. But like the other poster said, they are all different and I really believe it depends on who picks up your file that day. Appeal, have your PCP and surgeon write a letter of why your surgery choice is best for you and follow the appeal steps of your insurance company. Good Luck!
(deactivated member)
on 10/30/08 2:06 am - Woodbridge, VA
on 10/30/08 2:06 am - Woodbridge, VA
Is it because your BMI is over 50 (Lap Band is not recommended for high BMIs since only about 50% excess weight loss is expected long-term)? Your profile states a BMI of 53-point-something.
Also have you jumped through all the hoops such as a 6 month doctor supervised diet ( weigh****chers, nutritionists), Psychologist visit, 5 year BMI documented of 40 or over, PCP recommendation for weight loss surgery, I have seen alot of surgeons submit the papers as soon as they see you without inquiring about the other hoops if that is the case you need to talk to another surgeon because it looks like he is just trying to get customers for surgery. So do yourself a favor going through to get weight loss surgery is not a bed of roses you have to jump through all of the insurance hoops. Call your insurance company and ask them to send you a copy of what they require before you do anything.
(deactivated member)
on 11/5/08 4:03 pm - sunny, CA
on 11/5/08 4:03 pm - sunny, CA
In the state of CA you don't have to do the 6 month diet. It's good you've been under a doctor's care, but the medically supervised diet is unnecessary. I think alot of insurance companies deny you to see how serious you are about getting WLS. They deny because they can. If you meet the NIH criteria for WLS then your insurance should have to approve you, as long as you don't have an exclusion. You need to file an appeal through your insurance company and ask your surgeon to resubmit. Maybe you can have your doc write a letter of medical necessity to make your case even more strong that you need WLS. With you BMI being over 50 have you considered looking into getting the DS? It has the best EWL and maintenance of weight loss. Best of luck to you and don't give up. Once you've exhausted all your internal appeals through your insurance you can ask for an IMR with the DMHC. PS why will your insurance not approve the band? Do they give you a specific reason?