Denied by NJ Plus BC/BS Horizon. Now in a rage.
Me:
35 year old male
BMI >60
Sleep apnea, pain in knees/back, etc.
Here's my situation:
Last year, my insurance approved me within a WEEK after asking for insurance coverage for gastric bypass. Due to a number of reasons, none medical, I had to put off surgery. I reapplied for approval about three weeks ago.
I just received in the mail a letter denying coverage for a gastric bypass from New Jersey Plus BC/BS Horizon Insurance for not meeting the following "requirements":
"The member has a morbid obesity for at least five years."
Utterly ridiculous. I've been obese my entire life. And I was certainly the same LAST year when I DID get approval.
"The member has a BMI that does not exceed 60. Bariatric surgery for members whose BMI exceed 60 is considered investigational since it has not been proven to result in improved health outcomes in this specific subset of individuals."
WHAT THE HELL?! When did this become a condition?! I'd LOVE to chat with the doctor that claims THIS brilliant conclusion to be true. And the reasoning is obviously moronic.
<
Hi Drew,
I am sorry to hear you are going through this. I have BC/BS NJ, POS, and was approved. BMI at the time I was approved was 57.2. They did require that I do a 6 month dr supervised diet - was this a requirement for you as well? Pre diet, my BMI was just over 60. I also had to submit a 5 year medical history - basically the notes from all of my dr appts from the past 5 years. I actually only had 4 yrs of history as before that I did not have any reason to go to a dr. The notes clearly showed that I had been obese for years. In addition, I had to write a letter of support, where I outlined all of my previous attempts at dieting - from the time I was 12 yrs old until now. I dont really have any advice....but I would check with your surgeon's office and see what they are doing to appeal - I am sure this is an area they are unfortunately very familiar with.
Unfortunately, I heard recently that BC/BS is making it harder for people to get approved. I wish you a successful appeal.
Jenn
i am so sorry for all your problems
i have three words for you appeal, appeal, appeal
annoy them till they cave in, try and get to a case manager. the insurance companies are moronic.
but u need to persevere.
get letters from your primary doc if u have not already done this.
good luck, please hang in there.
hugs, jacki
hey drew,
dont give up.the ins.company just doesnt want to pay but they will you definetly need to appeal and i'm sure you will be approved before you know it.just dont give up.i have njplus which is bc/bs and i had no problem getting approved but the ins.comp. are making it harder for people to get approval probably because the surgery is getting very popular and is successful,i dont understand whyan ins.comp. wouldnt want to pay its saving the money in the long run with all the health problams people are having with being overweight.anyway stay positive and dont give up
Sean
I had a similar problem with BC/BS when I applied the first time... It was because of the procedure codes the doctor used... you should check in to that.. Long Limb was not covered (don't ask me to explain what this means - I never really understood) I changed drs and the new one used a code that would be approved...
Good Luck
did you use Barix the first time you were approved??
like everyone says -- appeal appeal appeal
good luck to you
roberta
Ross & Roberta Cassety Ross - Open RNY 5/22/06 - 373/194 - BCBS Horizon NJ
Roberta - Open RNY 11/22/06 - 228/126- Aetna QPOS
Let someone know that you are thinking of them
www.angelsforhope.org
Drew,
Just wanted to let you know that I had definately posted to this before - but for some reason it didn't show up - I just realized that today when I was reading the other replies.
Everything has been covered by the others already, so I'm going to just give you my support!
Pam
Instead of complaining that the rosebush has thorns, be happy that the thorn bush has roses. 
Most Active
Recent Topics
