I Was Denied

I just received a call from my surgeon's office. She told me that, unfortunately, the insurance company did not approve my surgery. My boot camp and surgery has been postponed. She told me that there is an appeal. I'm just so sick and tired of this whole thing. I have Horizon BCBS PPO, and my husband has Horizon Healthcare HMO. His is the primary medical insurance and it really sucks. Nereida

Hi Nereida, Sorry to here about your denial and that your feeling sick on top of it.  I believe in God so it will be in his time not yours, don't give up!!!  I will say some prayers for you that everything works out.  Keep learning like Roberta said, remember everything happens for a reason. Melissa

I'm sorry to hear about your denial, please don't give up.

I've heard (though I don't know for sure) that sometimes insurance companies deny things because they know a lot of people won't bother to appeal.  But if they do, they mostly approve it.  I hope that's the case for you!  My surgery is scheduled for the 17th, and mine still hasn't been approved, so I'm praying I don't have the same problem . . .

hi nereida sorry to hear about your denial  i can't stand it when a surgeon gives a person a surgery date and they get all excited and make a ton of plans for time off and help around the house and all and the surgeon's office doesn't even know if the person is approved -- i think it puts extra stress on the person and a larger fall when a denial does come  appeal the decision -- and stay on it -- take this time as a learning process to learn more about the surgery -- if you want the surgery and need the surgery then you can not give up -- everyone here will support you  good luck to you  roberta

Nereida, What was the basis for denial?  They need to give you a reason why.  I have BCBS PPO and I can give you copies of my letters from my doctors as formats if you want them, sometimes it's just a matter of wording.   If push comes to shove, open enrollment should be about now, unless it has passed for you.  If so, try to change yours to the primary if that's possible. There are also online formats for appeal letters. Also, the book "Weight Loss Surgery For Dummies" has outlines of letters for approval and also for appeal. Good luck, this sucks right now. Pam

Pam, I don't know what was the basis for the denial but I have a feeling that it had to do with my primary doctor's letter. I've never been on any supervised diet and the doctor wouldn't write that I was on any, which is understandable. I wrote the letter myself and he signed it, but I guess it wasn't good enough. I have hypertension, sleep apnea, and asthma, but I guess that isn't enough to have the surgery approved. The surgeon's secretary told me they are going to appeal. My daughter had to have nasal surgery back in July and it was also denied. I received a letter from the insurance company saying that the surgery wasn't deemed necessary and I imediately called the doctor's office. The secretary told me they were going to appeal and my daughter's surgery date wasn't cancelled or postponed. The day before surgery I received a call from her doctor's office telling me that the surgery was approved after the appeal. Nereida

Hi  Don't give up or be discouraged.  I too have Horizon HMO, I also work for Horizon.  I can tell you that it's all the luck of the draw.  Sometime you strike gold and sometimes you don't.  It's unfortunate though, because it doesn't seem like they (we) really have the patient's best interest at heart.  Almost like the company needs to meet a denial quota or something.  The company hates to go through the appeal process, so 9 out of 10 times, they approve it.  It probably had nothing to do with your PCP's letter, my letter was very basic and I was approved.  It also depends on how your surgeon's office presents/submits the info.  Hold tight, you will be fine.

 

Nikki, do you know how long the appeals process takes? My daughter's nasal surgery was denied the first time around, even though it was medically necessary. There was an appeal and we received an answer the day before her scheduled surgery, but I don't remember how long it took. In my daughter's case, I didn't have to do anything because the surgeon's office took care of all the details. In my case, my surgeon's secretary told me that they were going to appeal. The thing that bothers me is the fact that my surgery was perfectly scheduled to fall during my break from school, and now I don't even know if I'll have it at all. Nereida

Nereida,  Sorry to hear  you got denied but definitely start that appeal process!  Like someone else said, the insurance expects most won't bother with appeals.  You need a medical necessity letter from your Dr. /Drs. why this needs to be done.    Good luck!