Question:
Where do I start for insurance approval?

My insurer is Anthem Blue Cross Blue Shield, Option 2000 I'm not sure where to start. I filled out a qualification form from a surgeon's site to see if I would be eligible for the gastric bypass surgery. The office then contacted me to say that I seemed to qualify for the surgery. Before initial consultation the office wanted me to send my insurance information to see if they could get approval for me. They called me later to say that I had been turned down. Apparently I have been turned down due to lack of medical documentation. I have not tried any prescription diet pills (nor do I really want to) and I do not have a life threatening disease. I am wondering where I need to go next. Do I need to try to get a referral from a family practice physician or am I now wasting my time. I feel like I have a valid claim with my weight restraints, but have only been to see the doctor for a couple of individual things and never solely my weight. Some of my problems include extreme feet and leg swelling. (I am on water pills that somewhat bring the swelling down, but not totally.) I have shortness of breath and elevated heart rate just from walking from my car to my office and can't stand on my feet for very long at all without lower back pain. I have numbness that comes and goes in both arms, hands, and fingers. I have been referred to a dermatologist for a skin condition called hendronitis (sp?). I have bumps/boils on my skin where there is friction from clothes or touching skin. I have these all around my waist, between my legs, under my arms, around my groin and buttock area. They start as bumps and turn into bigger boil type bumps that burst and drain pus. My dermatologist feels that only weight loss will significantly decrease these bumps as I have tried many different prescriptions for them. She did mention having a tummy tuck to get rid of the ones around my waist but I feel that is a waste of money if my weight doesn't go down. I also feel tired all the time and get depressed about not being able to control my weight. I have been overweight all of my life. I am 28 years old. I have had higher blood pressure in the last year but am not taking any medicines for it now. I have not had a complete physical for years. I'm sure this little description is not all inclusive, but should be a good start for someone to look at. Can someone please tell me what my next step should be or if I should even try to pursue this at all?? Thanks for any help you can give. Please email me at [email protected] with any suggestions at all. THANKS    — Martha M. (posted on September 6, 2001)

September 6, 2001
Marth, I have the same insurance as you and am also in KY. However, I have not attempted to get approval yet. I think if I were you, I would go to your PCP to get a referral. I called Anthem a few days ago to see which Dr. were approved to do the surgery and the lady couldn't find the list but told me to start with my PCP for a referral,and then to call back to see if that Dr. is covered in the network. Don't know if I have helped any, but I feel like we are in the same boat as we have same insurance. I
   — Terri A.

September 6, 2001
Martha, Yes you need to go to your PCP and have him not only give you a referral, but also write you a letter of medical necessity. Be sure he includes notation that you've been overweight for awhile now, and that your past dieting attempts have failed. Do not get discouraged, it's important that you realize that a lot of insurance companies will deny coverage initially. It's their way of trying to get out of covering it. I was denied TWICE before receiving approval. BCBS is normally very good about covering IF you remain PERSISTANT! That, my dear, is the key! Call your PCP asap and schedule an appointment and take it from there...
   — Heather W.