Question:
approval process - got denied but there is a way to overturn it with additional info
— jenbn (posted on July 8, 2008)
July 8, 2008
After jumping through all of the insurance hoops (the detail I will spare
you but very similar to your situation), I decided to go to Mexico to have
my surgery. I opted for the Gastric Bypass at $11,900 vs the Lap Band at
$8500. (The Lap Band surgery in the states after my insurance paid their
share was going to be $7500 or $15,000 for Gastric Bypass). I had my
surgery within 20 days of my first inquiry. My experience was awesome and I
think I got even better care in Mexico. Good Luck!!
— monibunnie
July 8, 2008
I have BCBS and would suggest you get with your surgeons office and let
them advise you on the supervised weight loss and nutrition
— sistalee
July 8, 2008
hi,
Are you having surgery through a bariatric center? They usually have
insurance specialists who can help you with your appeal. THey do this
everyday and know exactly what to say. Also if you go on WLS.com they have
examples there too.
Good Luck.
— eyenjeff
July 8, 2008
The 6 months that the insurance is talking about is NOT Weight
Watchers...you must see a doctor every month for 6 months. This is my
experience with BC/BS...but certainly you should have a staff person from
the bariatric center/hospital that you are going to that will do all of
this for you. They should be working for you to get all the appropriate
information that will meet the requirements. They will get the whole
package together and send it all out. They should be using a check off
list and have it all ready to send when you have met those requirements.
Good luck and I pray that this will move along quickly for you, so you too
can feel the power in the after surgery feeling.
— usfour
July 8, 2008
Weight Watcher is not a clinically-supervised, non-surgical program of
weight reduction program. You can GOOGLE and get alot of samples of
letters, I had 5 family members write letters, 3 nurse friends write
letters and my primary doctor wrote a letter stating and showing that I was
seeing him for 5 years and that obesity was the reason for my check-ups.
You need to make sure you cross all your "T's" and dot all your
"I's"
— usfour
July 8, 2008
I found out that it was okay that it took some time to have all of this go
through. I needed the time, as this is major surgery and it is something
that you want to look into and investigate well. I think that most people
that go through their insurance will have 6 months of work to do to qualify
for the WLS.
— usfour
July 8, 2008
Go to an center of excelence. They can Help you work thru this
problem.
— stanwalker
July 8, 2008
Hi Jennifer,
I would think if your Dr is covered on your ins policy. He/She would have
the staff to do your request.
I first checked to see what I needed done and then the Dr.s in my ins plan
and proccded to find the Dr. that was the best for me & my ins plan.
Let me tell you it worked just like clock work..I have a MOST fantastic Dr.
We made sure all the pre reqs where done HE submitted the request for
surg and 5 days later we were approved and had my surg July 1st. I choice
gastric bypass over Lapband for MANY reasons. I am HAPPY with everything.
TALK to/with your DR. work together..it will happen. oh, I have Staywell
ins...Florida Medicaid. I willl keep you in my prayers.
— tootsie52
July 9, 2008
Hello Jennifer,
I actually work for an insurance company and just had bypass done. I deal
with many of these denials on a daliy basis and for what I have seen and
what needs to happen is the following.
First, when you appeal, you ONLY have one chance to appeal.
Second, many insurance companys require you to be involved and complete a 6
month lifestyle modification program before they approve you for surgery
and this does NOT include Weight watchers.
Usually a surgeon has a program as well as the insurance company. The
insurance company wants documentation of proof that you have failed atleast
a 6 month program for weightloss before surgery.
I know that the company that I work for requires a 6 month program that
they run to be completed before you are even considered for surgery.
I would contact a weightloss program in your area or speak with your
surgeons office. Normally if there is some documentation your surgeons
office can do a peer-to-peer conversation with the BCBS medical director
instead of doing an appeal. Again, appeal should be your last option
because if your appeal is denied, you can not appeal an appeal.
if you have any questions let me know
— blittlejr
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