Insurance denial

Hi,
I have done EVERYTHING that my insurance company requires.....I did the 6 month supervised diet, and at each visit my dr. documented 1400 cal diet and walking.  Every single visit this was documented.  We sent them the 5 year morbid obesity proof from doctors' records (I actually sent 7 years), My co- morbidities were outlined, I had my  long list of diet attempts through the years, I provided a letter of necessity from my pcp, and I wrote a letter why I wanted/needed this surgery.  Today I got a letter from BCBSTX that they could not approve me for this surgery since I have not given them evidence of a 6 month supervised diet with excercise, behavior modification etc...
WHAT?????!!!!!  What were those 6 months of doctors records??  I am so upset I can't see straight!!  Now I have to appeal, but I don't understand what I did wrong...or what I didn't do right?  Can anyone help?  I am going to call the insurance company personally and question them....is that appropriate?  I am sure my dr. office will help with appeal, too.

Did they deny you for a consult  with a bariatric surgeon or for the actual surgery? 

What type of insurance do you have? A HMO or PPO? If you have a PPO you can self refer to a bariatric surgeon (who is an in network provider for BCBSTX)  and they will help you get insurance approval for WLS.  Usually the bariatric surgeon submits for WLS not your PCP. If you have a HMO then all referrals must come from your PCP, so they'd have to refer you to a bariatric surgeon who would then submit for WLS. 

Write an appeal letter to your insurance asking them to reconsider their denial because you did in fact do the 6 month diet. Get the notes from your PCP and include them in your appeal. Include how long you've been MO, your comorbidities, etc... You could also include that Medicare covers WLS for patients with BMI > 35 with comorbid conditions; they do not specify a need for or time frame for supervised diet. 

Write up a letter for your PCP stating that you've done the 6 month diet, you've tried multiple diets over x number of years and failed, that you're a educated and compliant patient. 

Most insurance companies deny the first time out hoping patients will give up and go away. Appeal so they know you are serious about  WLS and won't just give up. You can call up the insurance and do an appeal over the phone but it's better to have it all in writting. Send everything certified mail.  Hope that all helps. Best of luck

Maybe they forgot to submitt it because that just doesn't sound right!

Let me tell you my ordeal and it may help you.   I had my own set of records from every single visit with my primary dr, lab, ekg. EVERYTHING I ever did or had done I had a copy of. Like i had my own medical file at my house. I waited until the surgeon's office had plenty of time to get everything from my clinic and then called to see if I was missing stuff. And os fourse I was but because I had my own stuff. I copied everything I had in my own file and faxed it to them. Then I gave them 2 days to fax all of that to the insurance. Then I called to make sure they had everything. Sure enough I was missing stuff. But the only thing I didn't have in my own file was an urinalysis which I never had done so I got that done and had it copied and faxed that to my own insurance and within 2 days it went to the medical revirew board and 3 days later I was approved. So may you can get copies of everything done from the time you started. The clinic and surgeon's office in may case were probably rushing or not worried about it. But I stayed on top of everything. Hope this helps.

Candie

I have Highmark BCBS and I was just denied for the EXACT same reason! I am trying to figure out what all to send in with the appeal. But I know how you feel. We do everything that is required and then we get denied?????? It just boggles the mind and boils the blood!!!
Good luck to you!!

My surgeon's office appealed and found out that the insurance company just didn't  understand something in the documentation from my pcp...(stall tactic?).  Anway, they sent it back for medical review and I got approved!!  I am scheduled for surgery on New Year's Eve!!  I hope everyone else gets their approvals, and thanks to everyone who offered me words of support.

Wow, what a fabulous way to start the new year!