Question:
HELP me, denied but don't know what they want!

I got my denial letter and it says the reason I was denied is "Member does not meet criteria 5 because counseling and an exercise program were advised prior to surgery yet the record documents neither of these interventions. Deny request for coverage of surgery for Morbid obesity". I don't know what this means, because I had a psych eval and was told I didn't need counseling-AND I am totally clueless as to where the exercise part came from...can anyone help me figure out what else they want from me??? My ins. is BCBS PPO...    — doit 2. (posted on April 21, 2003)

April 21, 2003
I was denied for the same reason. I then wrote an appeal letter and also went to my weight loss doctor to retrieve my medical records to show that I had tried almost everything including xenical, medifast, phentermine, etc. What they wanted was proof of recent participation in a weight loss program (less than 2 years). Don't give up. Be sure to appeal.
   — Von H.

April 21, 2003
I'm going for a stretch here but I wonder if they do not mean diet and exercise couseling. Did you work with a dietician and your PCP to develop an eating/exercise plan? If so, did you try to comply? If so, then document what you did and what worked and did not work etc. If you have any sort of paper documentation you did this then provide copies. <p>Like I said, I could be way off base, so call them and ask for details as you are not clear what they are saying. It doesn't sound to me like this is a forever denial and maybe can be changed soon with providing additional information you already can provide. <p>Just my opinion, but I believe everyone could benefit from some mental health counseling before and after WLS regardless of what your psych eval says. This is a huge change and having that support mechanism can be invaluable.
   — zoedogcbr

April 22, 2003
I too have BCBS PPO (Arizona) and I was denied for counseling reasons. As soon as I started some counseling, I was approved. If you are unsure why they denied you or where they got the information they based their denial on, call them! There should be a phone number on your denial letter, call and ask them to tell you what their explanation means and what you can do to get it reversed. I know we live in different states, but my experience with the BCBS nurse who worked on my file was very good, and she was very nice and compassionate. Just ask questions until you get answers that you can work with. Usually a denial is reversable, so make some calls and see what you need to do to satisfy their requirements. Good luck!
   — beeda

April 22, 2003
Get your psych to write your insurance company a letter. If you get the doctors involved, you might get the approval. don't lose hope, be patient, but persistent!
   — dolphins94

April 22, 2003
I have BCBS (Blue Choice Plan) and was denied because of criteria #5 as well. YOU HAVE TO FIGHT THEM! FILE AN APPEAL. Get a copy of the report/evaluation the psychiatrist did and go through it with a fine tooth comb. Point out every positive word they psychiatrist used indicating that the/she had no objection to the surgery and that he/she felt you were prepared for it or could handle it just fine. Email me if you want to see the appeal letter I sent--it's long--but it worked !! I just got approved based on my appeal last Thursday!!
   — dlpnjlp