Does anyone else's insurance lie???!!!!

Do Insurance Companies Lie?  Absolutely. Continually. Without reservation.  They are one of the largest for-profit businesses and that profit doesn't come from paying claims or approving surgeries.  I compare them to casinos.....having been born/raised in Reno I always tell people "The Casinos weren't able to build those amazing buildings by paying out money....so your chances of winning are minimal."

That said, I had to appeal my BCBS claim b/c they said I didn't have 6 months worth of s'vised PCP/NUT/Xrcize.  I successfully appeal'd the claim myself, but I was relentless in my efforts and my suggestion is that you take this very seriously, of course, and spell it out for them.  What you are doing, really, is creating evidence in case a civil claim has to be filed.  Sit down at your computer.  Chart out your weights from each piece of medical documentation you have been provided:

January 2005 = Weight/BMI, February 2005 = Weight/BMI, etc., etc.  Of course, you won't have each and every month documented but try to get something from each quarter of the year and as many months as you can.  Do a separate "chart" for each year. 

You want to show where your weight/BMI has been 35+ (if that is the requirement in your Plan Summary.  By that I mean, get a copy of the specific requirements from your policy. Verify that it says BMI must be 35+ for past 5 years and documented in the medical record.) for five years--make it clear and concise.  I am so happy you have found an insurance liason at Vandy (Cynthia) who is helpful.  But you are your own best friend when it comes to advocating for yourself in this process.

Remember, every letter you send to them is part of the puzzle that your attorney will use (if it gets to that) as evidentiary documentation to prove your case!  So, give her/him a lot to work with!! :). 

I am hopeful you will win this on appeal, but, realistically, until the insurance company knows that you are not going to lay down and let them walk all over you they will do all they can to deny each and every claim.  They have entire buildings full of staff whose job it is to find any reason to deny a claim--and sometimes w/out any reason at all.

If you need help writing your appeals letter, let me know--I am happy to review your draft and, if you can email me copies of your attachments, look at those, too when you feel you are ready to submit. 

As far as the "peer to peer"--that is typically the first step after the initial denial.  It is when your surgeon speaks directly with a Cigna hired surgeon to advocate on your behalf. They can be sucessful.  In my case, BCBS still denied my claim. 

What is important is that you find out how long you have from the first denial letter to submit it for appeal. DO NOT LET YOUR INSURANCE COMPANY DO AN AUTOMATIC APPEAL WITHOUT YOU INSTRUCTING THEM TO APPEAL IT BECAUSE YOU WILL NOT HAVE THE BENEFIT OF SUBMITTING THE ADDITIONAL DOCUMENTATION/EVIDENCE OF YOUR COMPLIANCE with the policy terms.  And you only get so many appeals, especially at an in-house level. It will go quicker the sooner you get your approval

You will have a certain number of days to appeal...make a note of that, build your evidence and hit them with an appeal they can't in good conscience (that is, if those running insurance companies had a conscience!!) deny---or, should I say, they won't deny because they know the cost of legal defense will outweigh the cost of surgery.

Good luck!!!! You can do this! xo, Micheala.