DENIED BY BCBSNC

I am in shock!!! Got call from Pat at VS in Fayetteville yesterday informing me that BCBS has denied my request for Gastric Bypass Surgery. I am so upset and unsure what to do. She said that I can appeal and that I should based upon the fact the only thing they stated was that I am not morbidly obese. BCBS insurance states that you can have a BMI of 35 or greater with co-morbilities and still be covered. Which I have hypertension and am on medication. It also states that you must have been at the 35 BMI with the co-morbility for four out of the five previous years. Which I have been. I am so upset but am for sure going to appeal as soon as I get my letter. Keep me in your prayers - I need it. Also, if anyone else has had this problem please let me know what happened with your appeal. Thanks, Donna

Im sorry Donna, maybe your surgeon can have a peer to peer phone conference with bcbs and that might work. adrienne

Adrienne - Thanks for the suggestion. Congratulations on your recent surgery. I am glad you are home and doing well. Take Care.

appeal first and if that doesn't work, consider calling an attorney...

Sorry to hear they denied you, Donna. We're all behind you on the appeal. If you meet the criteria of your insurance policy, then you have a chance. Good luck Lisa L.

Thanks everyone for the positive replies. I will let you know how it goes!! Donna

Donna, I had my surgery at VS on 2/20. I had the same problems you are having with BCBS. It turns out that over the years My Dr had indicated my heights varied which as you know, affects your BMI. I had heights recorded at 5'5, 5'6, and 5'7. BCBS used the 5'7 height even though I had indicated I had heels on the day my height was measured at 5'7. On your letter it should indicate the height they used. Also, I can tell you their BMI chart is slightly different than the one on the VS website. Did they break down the years and indicate the BMI for each year? If not, call them at the utilization # listed on the back of your card. NOT customer service. Get the information you need before you appeal. If it's a matter of one year being off, maybe you can find another medical record with a slightly heigher weight recorded that year.(They will use the highest weight you submit in any given year). If you have further documentation to support your appeal it should only take a few days to get an answer but you've got to have everything. Don't let Pat send in partial information. Be firm with her and tell her to wait until you're sure you have everything you need. I gave them a thyroid test to submit for me and asked her to send with some other stuff. She sent partial information and then it took me that much longer to hear from BCBS. Another word of advise, don't depend on Pat to get answers from the ins company for you. She doesn't take notes in her records, she'll never remember you from one time to the next and she doesn't mentally process information correctly. I've spent many times on the the phone with her trying to get her to understand what I needed or what ins needed and she just wouldn't GET it. I finally just started faxing her stuff and told her to forward it to ins and if she wanted to know why, I'd tell her BCBS told me to. (Just leave her out of the loop) I know this is very devastating news for you but it's not the end of the world. Just take it one day at the time and keep your head up. I started my journey 5/2005 and ended up having to submit a new claim 1/2006 so that I could meet the 4 out of 5 year weight history for BCBS but the wait has been worth it. It's been 4 weeks since surgery and I'm down 52 lbs!!! Email me back if you have any questions or just need to vent.. Take care-Pam

Pam - Thanks so much for the advice. I just spoke with BCBS and I still feel that I meet the requirements so I am planning on appealing. I have left a message for Pat to call me because I need the thyroid test results submitted to insurance. BCBS says they did not receive the information. Thanks again. Donna