Insurance Question

I just found out today that my insurance denied my coverage for my WLS. I worked very hard to make sure I had all the conditions met and still was denied. I was denied because I did not have severe sleep apnea, which should not even had to have played a factor in the decision because at the time my paperwork was submitted to the insurance company, my BMI was 40. The co-morbidity would have only had to come into play if I was under 40. Finding out I was denied after all my hard work and extra expenses for psych evals and consultation fees has depressed me quite a bit. I have been upset all evening.

My doctor's office is now stating we can do an appeal, but it will take going to my employer's insurance liason and convincing them to convince the insurance company's medical director to approve the coverage. Has anyone else had to go through this? Was your outcome positive? I am afraid to have any hope only to be let down again. Any thoughts and suggestions would be greatly appreciated.

Thanks.

GO FOR IT..FIGHT IT!!!! IT IS WORTH FIGHTING FOR!! I fought and fought...mostly with Doctors Offices but my last fight was with the insurance company, they said I submitted too much paperwork!!!!! Resubmitted the next day, approved 24 hrs later! It is worth fighting for, you are worth fighting for, your life is worth fighting for!! Do not give up!

Meggie!!

It took me almost 3 years of fighting with insurance, but eventually they approved me. Make sure you know EXACTLY every reason they denied you, preferably in writing. I had every requirement covered, then at the last minute they decided I had to have a 6 month medically supervised diet. After I did that, they relented.

Lynne,

I did have every requirement covered. I was denied because I did not have SEVERE sleep apnea, yet I had a BMI of 40 which should have even had to worry about a co-morbidity. It is only BMIs of under 40 that required a co-morbidity according to their requirements; however, my surgeon's office is appealing and I have also gone to my insurance liasons with my employer. Maybe if I get my hands in all the cookie jars and make a stink loud enough, they will approve me. My surgeon's office is just as appalled at my denial as I was because they agreed with me that I had everything covered. I am not back to playing the waiting game.

Thanks for the response.

You should fight and appeal the decision. Yes, it will take a lot of hard work. I have a friend that was initially denied by his insurance company and it took him a additional six months of gathering more information and fighting for him to get his WLS.

A co-morbidity such as sleep apnea is a sure way to get your WLS a approved but again you may have to appeal a decision. Have you had a sleep study done? if so did the doctor diagnosed you with sleep apnea?

I was lucky and had all my ducks in a row and went with a surgeon whose office was skilled with handling insurance companies. Each insurance company is different with the requirements before they will approve WLS. I do not agree with all the red tape that is required but You have to remember a insurance company is in business to make money. Also you could self pay or try to get a one of those medical loans to pay for your procedure. However, I would continue to appeal until you exhausted every avenue.

Most insurances require a BMI of 2 years or more. Have you been 40 or above for every year that your insurance requires? If they looked at co-morbidities it makes me wonder if they got a past weight that was below 40.

I had to have BMI of 35 or above since I have never been above 40. I had to have 2008, 2009, and 2010 weights with BMI of 35 or above for all years. I was denied because one weight was a hair below 35 (my pcp clocked a bad number or did not weight me and jotted something down. I got another dr's 2009 weight of mine, appealed....and won.

So check to make sure that all of the years are 40 or above, not just the weight you checked in with.