Got denied after 7 weeks of Waiting

Hi all, Got that dreadful denial today after 7 weeks of waiting. I have BCBS TN PPO. I did everything they told me too. Even did the 10% weight loss. I didn't have co-mobilities but my insurance requires 100 lbs. over weigh & bmi of over 40. Mine is 47 & I am a good bit passed 100 lbs. over. The insurance girl suggested my surgeon call. I just sent him a e-mail requesting him to do that. Does anyone have any good suggestions on the appeal. Especially if you have BCBS. I do have the WLS coverage. I sent a letter from my foot Dr. about bad heel spurs. My reg. doctor wrote that my knee & hips hurt regular. Of, course a bunch more. I wrote a 4 page typed letter of misarable fat experiences. Any help appreciated, Ellen Oh, the reason gave was Lack of Necessity.

Wow Ellen, that really sucks. I'm sorry to hear that. It sounds like you have everything they needed. I have BCBS TN PPO and had no trouble. Did you have proof of the 6 mo. dr. supervised diet? I sent all 6 months of my food journal and exercise log from the doc supervised diet. You don't have to have co-morbidities if your BMI is over 40. If you have everything.... I would definitely appeal. Give it another shot and call every other day and let them know you mean business.

Hi April, It didn't state it had to be 6 months just had to loose 10%. I lost it in 3 months so my caseworker said were sending paperwork in. That hasn't been mention from the insurance end. I did have past diets documented also. Thanks Ellen

hey ellen, i am so sorry to hear about your denial. i can only imagine how upset you must be. i don't really have any insight on the subject ( i had cigna and they approved me in a day ) but i just wanted to give you my support, and to tell you i am thinking of ya, goodluck with the appeal!!! *big hug* Jacqueline

Hi Ellen, the lack of Necessity means each of your Dr.'s have to write a letter of referral stating that it is "Medically Necessary" that you have this surgery. Plus a 6 month Dr. Supervised diet program, and as April said, send that along with all your records, your 6 month journal, and you shouldn't have any problems getting approved. May God travel with you on this journey, Kathy

Just a question... but did your PCP write a letter to Blue Cross, stating specifically that you had done a weight loss program within the past two years, and stating your original weight and bmi and then your now weight and bmi (after 10%).?? It should probably say "SHE HAS LOST HER 10%" as I found that they do not read medical records! Jeesh I sent them 110 pages and I dont think they ever read it!

Hi, Yes, she did write the letter. It, with my documented 10% loss & past diet history was all included in a 45 page file. Thanks Ellen

Ellen, You know that I am right there with ya.. and I will help you in any way! I have been researching on appeals, and etc... because I have to write my own! There is a reason why its not working right now.. for you and me both! I know that the Lord has a plan, and that in His time He will give us the desires of our heart. (we are promised in His word) We will get through this.. dont you dare give up! I am praying for you, and your strength and your courage for you to be able to do what you have to do to see the end result! Keep your chin up! Yell if you need me! Be blessed, Sonya

Ellen, I just read your post and I'm so sorry you got denied. I had Horizon BCBS of New Jersey (through my employer) and it was fairly easy getting approved, though I had to go through a lot of red tape. I had documentation from my pcp,therapist, psychiatrist, and nutritionist that I was under for at least 6 months. I know what it feels like to be denied. I was under Aetna and was denied twice. in the three years I actively pursued this surgery. I do know that I was very pro-active and did not leave anything to chance especially when it came to my surgeon's office. When it looked like I was getting a possible denial from BCBS, my answer from the insurance rep/office manager was to get a new insurance company. I wish I had some answers for you, just be very dilligent and on top of things. I've been there and know how it feels. -Alyssa