Insurance Denial

Hi everyone, Well, I spoke with BCBS this morning to check on the status of my pre-determination sent in by Dr Clark's office. They just finished reviewing it this morning. DENIED...because even though I did go to Weigh****chers for the required six months, it was not documented in my office notes with my PCP. That is the only reason that they denied it. Even though I sent them my weigh-in log, cancelled checks, credit card slips, pre-paid slips that showed that I did do this for six months. Well, after speaking with the rep from BCBS who, by the way, was very pleasant, she suggested that I contact the PCP and see if there is some way that notes can be added to the effect that I did go to WW and list my weight on each visit. So, I called his office to see if there was a way that he can do some addendums to my chart to show that I was attending WW for those six months and my weights at the time. Should be ready by Monday, I was told. I guess at that time, I can the info resubmitted with the requested information. I hope they will accept this new information as I don't want to have to go through another six months of this. It's so frustrating, you get THISCLOSE and you get yanked back a few notches. Oh well, I will keep you all posted of my progress with BCBS. Keep all your fingers, toes, eyes, legs etc. crossed for me. Has anyone else had this happen to them? It just seems so trivial that they would deny just because my MD did not indicate in my chart "on Weigh****chers" when I have so many pieces of proof that I did attend for over 6 months.

Ebonie- Hang in there! Insurance companies are not in the business of making things easy! (at least in my opinion!) You have the proof, your PCP is willing to work with you and so you just need to take a step back and breathe. Everything happens for a reason and in the proper time. Christina S.

Ebonie, When I had BCBS, it was very easy. If you were at least 100lbs over and a BMI of 40, that was it. No paperwork, no hoops to jump through, nothing. However, they realized they were way too easy and changed their policies. My plan actually stopped covering WLS althogether with out a rider. But because I had it when they covered it, they would cover my follow ups for 2 yrs. BUT, my employer changed to Optima this year. They won't touch me because I've had a GB. I got my pre-existing conditon letter a few days ago. Basically, because I have had GB, they won't treat anything remotely related. If I break my arm, yeah, they'll cover that. But forget them covering my abdominal pain, or the fact that I need additional surgery. I can't get followup blood work, dietician counseling, nothing at all related to WLS. If my PCP checks the box on the form that I have had a GB, even if I am seeing her for strep throat, they will deny the appt and refuse to pay. What annoys me the most, is my HR KNOWS I had this done. She went out of her way to make sure that another employee who had surgery scheduled with out old insurance was covered. But I didn't find out until the last second that I won't be covered. Its really upseting. I think if you KNOW you have an employee with a particular medical condition, you make sure its covered. We have an employee with cancer. One reason we dropped BCBS was because her Oncologist wasn't taking our insurance. Well how nice, they are making sure 2 people are covered, but what about the rest of the world? Its upseting. I now have to find some other coverage. Because I can't just NOT be treated. This abdominal pain is killing me. Leland

Leland, I'm self pay and scared to death that my insurance won't pay for ANY abdominal problems I have in the future whether or not if was GB related. I don't know what I'd do. JennV

Ebonie, I am sorry to hear about your denail. I have BCBS as well, and I was not required to have a six month weight doctor supervised weight loss. Is your BCBS also with Anthem?? I just found that to be wierd. I am glad that your pcp will be able to add the information that is needed. I hope everything works out for you. Melissa

Hi Ebonie, Sorry to hear that you got denied. I went through the same thing for the same reason. My plan won't accept weigh****chers. It has to be strictly doctor supervised. I did the first 4 months with a diet doctor who had impeccable notes and did the last 2 with my PCP. At the instruction of my surgeon's office, she merely noted that we discussed diet and exercise and weighed me monthly (although we discussed the plan that I had been following at each meeting). I got DENIED!!! I went back to my PCP and she added an addendum clarifying what we discussed as far as calories and amount/type of exercise. Then, I got APPROVED!!! Don't worry, it will all work out! Good luck! Christine

Ebonie, don't worry about girl. Just keep your head up and know that you just have to do a little extra to your quest for a healthier you. I have Federal BCBS and all they required for me was to be 100lbs overweight, over the age of 18, and it be medically necessary. No documented weight loss attempts, or supervised diets, not even a referral or anything. As a matter of fact the day the submitted my papers to the insurance company it was approved. It only took me a week to wait for an answer!!!! It will happen for you. Whatever else they are asking for try your best to get it and then go from there. I will keep you in my thoughts and prayers sweetie!!!! You need to join us on the "Losers" side!!! Yayyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy..... Good luck and let us know! Kennie

Thank you all for your replies. I am going to see what happens when I resubmit with the new information. if not, then I'll will figure out to go from there. I am not going to give up on this. It's a shame. You would figure that the insurance companies would see that this procedure would save them tons of money in the long run. Go figure.

Hi Ebonie... I am sure the doctor's office will work with you if you have a good relationship with your PCP. Most medical professions lack in the area of documentation. I, myself, have been burned by not adding enough information in my charting. So usually when you ask them to add something that was left out, they don't have a problem. My doctor wrote a letter for me with everything in it...so I kind of went through what you are going through. I am sure you will be approved. This part right now just sucks....but you will be persistant and get through the red tape !!! Hang in there kido !!! Hugs and Good luck !!! Dana

Aww, Honey, I am sorry for the mix up but don't give up. Your approval will come through in no time...alot of us have "been there and done that" so we all know what you are going through. Insurance companies seem to not want us to get healthy! Hugs, Betsy