Denial Received - Now What?

Let me begin by saying my insurance is Wellmark Blue Cross Blue Shield of Iowa.

I had my information session at the University of Chicago on my birthday, April 26th, and my surgeon/psych/nut consult on April 27th. Everything went extremely well, and I was approved by Dr. Alverdy's team for surgery on April 29th with very few requirements (only needed a letter of medical clearance from my PCP, a copy of my latest hemoglobin A1c bloodwork, and participation in a mandatory PREP course). When Tracie from Dr. Alverdy's office called me yesterday to go over what paperwork was still needed, I found out she had already submitted the prior approval request on May 3rd. Needless to say, I was ecstatic, and also worried.

I received my denial letter in the mail yesterday, citing the following: "Based on the information available to us, this request does not meet medical necessity and is being denied as of May 3, 2011 based on the following: There is no documentation of physician monitored weight loss attempts within the two years prior to the procedure as required by medical policy."

I know there are many, many posts out there about being denied and asking how to proceed. I apologize in advance, because I am very frazzled right now. I'm not sure what my next step is. I don't know if I need to contact Dr. Alverdy's office, or if they will contact me, or if they will contact the insurance, or if I need to contact my PCP. I know I just received this Friday, but apparently there is a time limit for appeal. Any help and advice would be so appreciated right now.

The hard part for me, I guess, is that I don't really understand how they access your personal medical records from your PCP in the first place. There is a section on the denial letter that says: "Your physician has the right to speak with the Wellmark Medical Director regarding the requested service by calling the customer service number on the member's health card."

Sorry this is so long, but right now I don't know my next step, and I don't like to feel helpless. If anyone can help me with what I should/can be doing, I would be so happy and relieved. Thanks for listening.

I would start by calling the Surgeons office and asking if they provide any asistance with denials. If they do, they will be able to tell you what you need from them
If they do not, ask them to provide you with your medical record and aslo call the insurance company ans ask them what specifically are they looking for and who should the infomation come from.
This is a start. 

I am going through an appeal, for a different reason. If you have any additional questions, let me know I can try to help.

Ok I'm actually going through the steps to get approved right now, so I actually know what you are missing.

1. The insurance company didn't go through your medical records, they require that proof of a medically supervised diet be submitted with all the other paperwork to get approved.

2. There is no way to appeal that denial if it is in their outline for requirements.

So here it goes....My insurance also requires an attempted medically supervised diet for 6 CONSECUTIVE months to even be eligible for approval.  You need to call your insurance company asap and ask them for a copy of their bariatric surgery guidelines (this really should have been your first step in the whole WLS process).  In that outline, it will have everything the insurance company requires to get approved.  Many insurers require the medically supervised diet. You need to find out how long they require it (most are 3-6 mo) and if there is outcome critera, such as a "failed attempt", or that you must lose 5% of body weight, etc.  Then you will have to suck do it.  I know it sucks!! I'm doing my 6 mo diet right now too. But unfortantly there isn't a thing you can do about it. Your surgeon's office may have a program that you can take, or you can just go through your PCP for it.  Then you'll have to resubmit all your stuff after you complete that requirement. 

So to answer your question...first contact your insurance, then your surgeon, then your PCP (if that's where you will do your diet).  Trying to appeal this will be a waste of time UNLESS there was nothing written that it was required, but I think this was just a matter of not looking into the requirements closely enough.  Good luck! I hope this helps.

Agree with the pervious poster your firt step in ther process should have been to contact your insurnace company and get a copy of the requirements for qualifying for surgery.  I have Aetna.  They have a 'clinical bulletin' that spells out the requirements.  I used this as my checklist to make sure I met each and every requirement.  If all requirements are not met, they will deny.

Based on the reason you were denied, it sounds like your insurance requires a 6 month physician supervised diet (as do MOST insurances).  This means you have to start with your physician and go 6 consecutive months (not missing one month or they will deny!).  It entrails weighing in, tracking BMI, followoing a reduced calorie diet, etc.....they want to see an attempted weight loss for 6 months, documented in the office notes of your pcp.

Did you do that in the past 2 years?  If you did, you can appeal by proving you have done that by providing copies of the office notes from your pcp.  If you did not do that yet, you need to complete the 6 month supervised diet, then resubmit for approval.  There's no getting around it if your insurnace co requires it.

Good luck to you!

I had to do 6 months of supervised program, but it was NOT required by my insurance company. I have Anthem BCBS of CA.,  but I live in Maryland and surgeons have to follow BCBS requirements for pre-authorization in said state, and Maryland requires 6 months documented diet within the past 2 years (2, consecutive 3 months or 6 consecutive months).  Before finding out about the state requirement, I actually posted about the 6 months requirement when I first started out and one member suggested I could file a grievance, here’s part of the response: Second, if it is your insurance, find out whether your insurance policy is fully funded, and if it was "issued, amended, delivered or renewed" in CA.  If so, your plan should be covered by the DMHC rules.  You can file a grievance with the DMHC and they will order the insurer to waive the requirement.  http://www.dmhc.ca.gov/aboutTheDMHC/org/boards/cap/Bariatric REV.pdf

See also http://www.asmbs.org/Newsite07/resources/ASMBS%20Position%20 Statement%20on%20Preoperative%20Supervised%20Weight%20Loss%2 0Requirements.pdf

Hope this helps, Good luck to you 

I have a question if anyone can help. My company also requires a 6 month medically supervised diet but I am considered a revision having my band removed 3-21. Do you think they are going to make me do this diet thing? It is listed as a requirment for surgery but not under the revision part. I am so stressed over this...