Appeal Update

I wanted to update everyone on my appeal for gastric bypass. I received my letter yesterday and was denied. However, it stated the reason as my BMI not being between 35-40 for past 4 out of 5 years. I knew this wasn't correct so I called the contact on the letter I received. In my medical records, my height had been listed as several different things because, in the past, if a doctor asked me how tall I was I would say 5'6" or 5'7" so this was put in my records. I was recently measured at my doctor's office at 5'5 1/4" and this height also was on a medical record submitted to the appeal office. I addressed the discrepencies in my appeal letter and stated the date and doctor who actually measured me. However, they chose to use the higher height of 5'7" to calculate my BMI. My contact said I can file a second level appeal with a letter from my doctor with my height and signed by him along with another letter from me. I am very hopeful at this point because I know this is fixable. My question is this: They could have actually picked one or two other things as reasons to deny my appeal. If I send them proof of my height which then changes my BMI to acceptable ranges for approval, can they pick something else to deny me on? Or once I prove their point wrong, do they have to approve me? I have been mostly a lurker and have really enjoyed this group and get a lot of good information from you guys. Thanks!

I am so glad to hear from you although I wi**** was better news. However, do not give up. As you know from our prior communications I was denied my first attempt. I was told to address only what they gave as your reason for denial in your denial letter. I would not draw attention to anything else that you feel they might could suggest as a reason for denial. Just get that second appeal into them asap and it sounds like you have an excellent chance. In addition, on your appeal letter it also has a number for the treating physician to contact where he can request a consultation with a Regional Medical Director (1-800-672-7897 ext. 51019) and can explain the sitatution to them and I have heard that sometimes they will approve without a written request for approval. That is only if your surgeon or probably primary care physician would call. Nevertheless, I am sure things will turn out great for you. Please keep us posted. My sister 3 1/2 years ago went through 2 appeals before approval with BCBS so stay optomistic. Donna

WELCOME!!! I hope your appeal goes smoothly and things progress quickly!!! Welcome to the NC forum. Let us know how things are going. Pat

Is the requirement 35-40 w/co-morbities? I got denied for the same reason... I always said I was taller than I was I appealed, the records were updated but was denied again for not meeting the co-morbities. Read the letter fully and make sure of everything they denied you for. I would appeal not only the height issue but whatever other requirements of theirs you already meet Of course they can still deny you even if you prove you meet the height... they are the insurance company! they count on the fact of people giving up out of frustration! Just keep hope alive

Tiger 51.They denied me the first time because the Dr never put down I was a non smoker.Once they faxed that I was not then they reviewed my case.I think from what everyone told me .They stop when they see you don't meet basic qualifications and then after you meet them as you will they begin to read your case.You will if all else is in place will most likely get approved.It took Medcost 4 days to approve me after they got the correct info.Good luck.Dee