Denied

whatazor
on 10/16/08 8:46 am - lake elsinore, CA
I had my first appointment last Thurs. the 9th and I was denied on Tues the 13th.What is my next step?
Can anyone with experiance with a blue cross PPO help? 
(deactivated member)
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?
TeresaJay
on 10/17/08 11:37 pm - Greensboro, NC
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!
"There is a skinny woman trapped inside of me. I can usually shut her up with cookies and chips but today I am setting her free" 
whatazor
on 10/19/08 3:46 pm, edited 10/19/08 3:47 pm - lake elsinore, CA
Thank you for the replies . first I have Blue Cross PPO BMRS.I didn't know there were hurdlers to jump  through to get this done.i am going to get the lap-band one way or another.Thanks for all the help.
Vicki Browning
on 10/21/08 3:54 pm - IN
IF you been denied you should file an appeal if you need help let me know
whatazor
on 10/28/08 4:20 am - lake elsinore, CA
I was officially denied .My insurance will approve all other surgeries but the lap-band, and that's the one I want.I don't know what to do....any help would be appreciated. 
(deactivated member)
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.
renegadebkr
on 11/4/08 10:08 pm, edited 11/4/08 11:52 pm - Waldorf, MD
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. 
Dusty Cassidy   " It's not a real adventure unless you come home with a scar "                    
Current weight  219.0 Lbs   My  Ideal weight  188   I love my sleeve 
                                
whatazor
on 11/5/08 12:39 pm - lake elsinore, CA
Thanks for all the replies.I have been under a Dr's care for over a year and a half(diets, perscriptions drugs etc.)
I'm just going through the process and waiting. 
(deactivated member)
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?
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