I GOT DENIED!! - HORIZON NJ/BCBS

oh you have ppo, see pos and hmo don't require it..it is the level of horizon blue cross and blue shield of nj that you have that makes you have to have that 6 mos supervised diet

I know how you feel. I have the same ins. I did the 6 month diet then they still denied me. They wanted me to take diet drugs. I just stopped that due to complications. I hope a letter from the doctor why I was taken off of the drug would with no weigth loss will get me approved b the ins. Good Luck.

Sometimes a primary care doctor can document that you have had the 6 months of supervised dieting by reviewing you chart. My doc put me on a number of diets before he finally consented to refer me to a WLS surgeon, so he was able tyo document for Horizon that I had already been on supervised dieting plans. But all this talk of people gaining weight to qualify....Well its just ridiculous. I know that I am someone who has already had a sucessful RNY, so maybe I am not feeling the frustration that others are feeling...But I have to say feeling anymore. because I certainly had ups and downs in my approval process. If your BMI is too low and makes you ineligible for the procedure; you don't need it. If you gain weight just to become eligible you are putting your life at risk for a procedure that in and of itself is life threatening. Many surgeons, including mine, will cancel a surgery if a patient gains weight during the approval process. The BMI requirement is not some arbitrary figure that insurance companies have adopted in order to stop the so-called lazy dieter from having WLS. There is a range of weight, and a range of weight with commorbitiies because this is a radical procedure. Everyday, I see advertisments and magazine articles about WLS that makes it seem like a walk in the park. It is not. It is a very dangerous procedure. The obese person having any kind of surgery is taking a big chance. This procedure, meaning RNY, has a particiularly frightening death and complication rate. And before I get flamed by the overeager who are afraid to hear anything negative about WLS. I strongly support anyone's need and desire to have this procedure. But the rules are there as a saftey net for all of us. And two things to remember about insurance companies. Every employer or individual makes its own purchasing agreement with an insurer. Even if your sister has Horizon PPO, she may have completely different requirements for any procedure than you do. An example, my sister has Horizon and so do I. She has to have every blood test she needs done at a Labcorp. I can get mine done at the PCP's office. We pay the same co-pays and everything, but her policy is issued by the State of NJ, as she is a state worker and mine is from a privately owned company. Also, they often deny people on the first go round, no just for WLs surgery, but for other kinds as well. I was denied coverage for impacted molars that needed to be removed in a hospital. After letters from both my PCP and my Oral Surgeon I was approved. I think most people who otherwise meet surgical criteria will eventually be approved, but they have to "play the insurance waiting game first". I used my waiting time to get as fit as I possible could before surgery. I water walked at my gym and I went on a diet that I cheated on quite a bit...But in the end I was approved. I had a complicated recovery, but have been very successful. I am sure you will be too when you climb these frustrating hurtles.... Good Luck. Kelly

Do you have any co-morbidities??? I have Horizon BC/BS....no pre-diet requirement. I do have sleep apnea, and a family history of high blood pressure, high cholesterol, and type II diabetes --even though I don't have any of those ---they approved it as a precautionary measure.....cost of surgery is so much less than the cost of treating the illnesses!!!! Was this your first denial?? Call them back....talk to the nurse. Hmmm.... I am wondering though, didn't your doc's office do all that for you? My doc's office handled everything, I never even had to speak to insurance. What my doc did too, was get all the test results ---everything---and then submitted it to my insurance..kinda like here she is and this is what we want to do and why.....worked like a charm! Take care!