Question:
PLEASE, SOMEBODY HELP!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
WE ARE DESPERATE FOR AN ANSWER. MY BROTHER HAS ANTHEMS BCBS ACCESS PPO OF KY, AND THEY HAVE DENIED HIM THIS SURGERY TWICE. HE DESPERATELY NEEDS THIS SURGERY. HE HAS HIGH B/P SWELLING IN HIS LEGS SO BAD THAT THE FLUID LEAKS OUT. KNEE AND JOINT PAIN. HE HAS RECENTLY SWITCHED DOCTORS THAT SAY,S HE IS GOING TO DO EVERYTHING HE CAN TO HELP HIM GET THE SURGERY. HAS ANYONE BEEN APPROVED BY THIS INS FOR THIS SURGERY? PLEASE GIVE ADVICE ON WHAT WE SHOULD DO NEXT. WE APPRECIATE YOUR RESPONSE. — pmcconnell3004 (posted on May 14, 2007)
May 14, 2007
you may need to write a third and maybe a fourth letter..whatever it takes.
Explain that this surgery is to save his life. Explain that without it
there is an excellent chance of him dying very soon. Also explain that with
it his medical needs will diminish and actually save on medical cost saving
them money. What I'm saying is GET TOUGH and DON"T GIVE UP.
— donnyj53
May 14, 2007
email me with your personal email and I will email you some examples of
appeal letters that may help. I can't attach them using the OH website...
my email is [email protected]
— Kari_K
May 14, 2007
An attorney may also be able to help!
— jlw0423
May 14, 2007
Hi Patricia! My sympathies and love to your brother, he must be a very
strong person to go through all that. I'll pray for you guys. That said,
if all else fails, how about talking to somebody at your local TV news? Do
they have an investigative reporter? Something like this, little guy
screwed by big corporation, makes a good story, especially around sweeps
time (pardon me while I mop up a big puddle of cynicism). If you can stand
having your private problems exposed to the world, it might just shame BCBS
into approving the surgery. I'm constantly amazed by the "Penny wise,
pound foolish" attitude of insurance companies. They'd rather save a
few dollars now by denying the surgery, but are willing to pay endlessly to
deal with the health problems that the surgery would have solved. Go
figger! Good luck! -- Mary
— mwilson523
May 14, 2007
I also have this insurance and also got a denial but with the help of the
people at my weight loss mangement center we finally got an approval. It is
hard to wait but and hard to understand why they deny things but try to fix
the reason they denied it and go thru every appeal process you have to do.
It is the job of the insurance company to not pay for the operation. Good
Luck!
— Alvernlaw
May 14, 2007
It could be there is an exclusion on the policy for weight loss surgery of
any type that his company was not willing to cover through the ins.
carrier. I had this problem and ended up self pay. Make a phone call to
the insurance carrier and ask if there is an exclusion on the policy. If
they do cover, file an appeal.
— R. biles
May 14, 2007
I have this insurance co. as well. I was denied the first time but
approved the second. I know they need all kinds of prerequisites: 6 mo.
supervised diet (mine consisted of 6 mos. of visits due to back injury (the
dr. had a good idea of all the diets I have been on, but we went over
everyone of them. Diet, length of time on it, results, weight regained), 5
yr. weight history (this can be a bit of a battle if you haven't been with
the same dr.), 2 nut. visits, 1 physical therapy visit, pcp letter,
pschological evaluation and surgeons mandatory seminar. My surgeon
wouldn't see me until after insurance approval, but after the first denial
due to information only the surgeon could provide, I had my appointment and
less than a week later a surgery date. I found the pcp carries the most
weight with insurance companies. Also, the person that handles the
paperwork submission should know "exactly" why your brother was
denied. I decided on surgery on Oct. 31, 2006 with an extra push from the
pcp, had surgery on Jan. 31, 2007. It all fell into place for me. I wish
the best for your brother. Keep submitting until the approval. It's worth
the hassle.
— Darlene G.
May 15, 2007
Hi Patricia. I am sorry for all this stuff that you and your brother is
going through. Fluid leaking from his legs, wow, he has to be in some
pain. You don't say many things Patricia, like if his insurance policy
covers wls or not, or why he was declined. You can continue to appeal, and
through this website I think you might be able to find an avocate or
attorney that may be able to assist your brother in his need. If they do
not cover wls in his policy, I am not sure there is much that anyone can
do, but if they cover it and deny him, and he qualifies, then you have a
fight to fight. Attorney's may be able to wiggle through other issues to
get more blood out a turnip, but you may be up against a brick wall for
sure. Just know that just because you are up against a brick wall, that
doesn't mean it won't come down. God brought down the walls of Jerico in
the Old Testament with the command of the sound of a trumpet and silent
marching Israelites. My strongest defence in my wls journey has been
prayer with the God of Heaven whom I love and serve. It may sound like a
last order of defence, but I choose it as my first. Hope you will consider
seeking God in regard to your brothers care. Take care, Patricia P.
— Patricia P
May 15, 2007
JUST TELL THEM THAT YOU'LL HAVE TO GET YOUR LAWYER INVOLVED. THAT MAY
HELP. NEVER GIVE UP. THERE IS A LAWYER ON THIS WEBSITE AS WELL THT YOU
CAN ASK.
— DDBEAR458
May 15, 2007
If he gets letters of medical necessity from both his general care
physician and the bariatric surgeon, stating, that his life and well-being
is at stake unless he has the surgery, they cannot refuse to pay for it.
These insurance companies just bank on people not taking the time to get
involved, write letters, and go the nine yards. Hang in there. It will get
done. Also, the weight loss surgery books out on the market are very good
and give you good samples of deny letters and how to get coverage. Good
luck to you!
— blm4602
May 15, 2007
If you or anyone needs appeal information, I did a great deal of research
for my appeal to Medicaid. I found the NIH (national institute of health)
and the FDA (food and drug admin) BOTH state medically supervised diets
often FAIL or even work in the first place. Here are some of the links I
used (along with copied text from these sites) to overturn my ridiculous
denial for one full year of medically supervised diets.
http://www.fda.gov/cdrh/pdf/P000008b.pdf
http://consensus.nih.gov/1992/1992WeightLossta010html.htm
http://www.uihealthcare.com/depts/med/surgery/weightloss/understanding.html
And then I found where this lady appealed to the NMR (National Medical
Review) about her insurance's insistance on denying her this surgery. She
had a lawyer and after the NMR reviewed the b.s. denial from her insurance,
the NMR ordered her insurance to pay for the surgery.
http://www.michigan.gov/cis/0,1607,7-154-10555_20594_20596-82522--,00.html
I personally think it was the fact I did my research and found 3 top
GOVERNMENT agencies that not only stated most diets are doomed to failure,
and one actually ordered an insurance to pay for the procedure is what
"forced" Medicaid to overturn my denial. I really hope this
helps as I used to have Idopathic edema (swollen from head to toe and
dieuretics only made it worse) but I didn't "leak". God Bless
and good luck!
— crystalsno
May 16, 2007
I work for an insurance company (not Anthem). Let me tell you one thing:
when surgery is denied, there is a denial reason listed in the denial
letter. When an appeal is made to the insurance company, that reason must
be addressed! Forget the emotions, and "it's to save his life".
If he does not meet criteria for whatever reason, then there needs to be
documentation that he does meet criteria, or reasons why he should be
granted an exception. If the policy simply does not cover the surgery, many
times that is because the company he is employed by has chosen to buy a
plan for employees that does not include that coverage. Send me an email
and tell me what the denial letter said and I'll see if I can help. ( I can
tell you that high blood pressure, if controlled, is sometimes not
considered a co-morbid condition. Things like diabetes and uncontrolled
hypertension are considered co-morbidities. Joint pain is usually not,
since people of normal weight can also have joint pain. The swelling in his
legs is debatable - depends on why the swelling is there, and it is not
always attributable to obesity.) I'm not trying to sound mean, just telling
you how insurance plans look at things.
— koogy
May 16, 2007
I have blue anthem ppo...they denied my request the first time...i appealed
a week later...and the following week i got my approval letter...it took me
8 months for all this...now my surgery is set for june 29th...
— christy_jean
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