I just received my letter of denial for my LB surgery. It says "that my policy clearly states that they will not pay for any obesity surgery of any kind. I will have to be dying first, befor that happens. I have a bunch of mony put into this. If I wasn't going to be approved sooner or later, why did they proceed on. I'm also peed off at myself, for not reading our policy first myself. I tried to access it online but it would let me get into our policy. Any suggestions?
In the beginning, they told me (surgeons office) that all I needed to do was xyz and it was pretty straight forward about it. Well, I guess thats not the case. Any ideas out there on what I need to do next?
I don't like insurance company policy! It's all about the dollar. I think...Sometimes, the wording in the policy allows them to "play" with the meaning of what they will and will not cover. So it looks good to someone buying the ins. until you want to use their money.
If you have Blue Cross, they took the coverage of WLS off the list a few years ago. I think because more and more people were using the surgery and depleting their profit margin...not the reason they claimed though. From what I understand from my Dr., the deaths/complication % had dropped dramatically in the last few years and has continued to as they perfected the techniques. They are using older studies to prove their point. Not sure about that...but I hoped that the private insurance companies, like Blue Cross, would take notice of Medicare's decision to pay for WLS as a preventive measure and reverse the decision...wishful, I suppose.
Maybe you could bring up the medicare decision, and throw THAT at them! I'm never too ladylike for a good brawl!
Seriously...You never know, you might be able to affect change in your insurance company.
I was denied initially, too. I filed an appeal and I think I had to do some extra stuff......red tape kinda things.....and then I was approved. I'd start there! I remember that my doctor had to write a letter saying all the reasons he thought I needed the surgery, and all the diets I had tried...that kinda thing. Keep us posted!!
Just pick yourself up and start all over again. Remember you were probably denied by someone sitting at home that doesn't even realize how important this surgery is to you. That's the part that always makes me angry, but do begin asking questions again and ask them where do you begin again. Let them know that you're not going to sit still and that you will pursue this further. I would file an appeal, but I'd check out the above first.
Good Luck.
I am really sorry that you pre-cert was denied. I do want to share a few things with you though. There are several flavors of Blue Cross Ins. (like different flavors of ice cream). When I originally had the drs. office do a pre-certification on the WLS for me, I was denied also. I work for a very large insurance company & work from home 40% of the time. Where I work does not mean that I don't care about my customers.
The company I work for has a self-funded health insurance plan administered by a Blue Cross. My husband is a minister and the insurance for our denomination (nationally) is also a Blue Cross. When I was denied, I called the Blue Cross companies and found each of the customer service reps very helpful. 1) The doctor's office submitted the claim with my husband's insurance as primary & they didn't cover WLS in addition to needing to know that the claim would be submitted to the primary carrier first. 2) When talking to my Blue Cross Rep, & asked what needed to be done for them to pre-certify, she gave me the information that the dr. needed to know to submit the claim to have it covered (the correct codes). 3) I shared these pieces of information with my drs. office & they made the needed changes & my surgery was paid for entirely except for $300.
Just because you were denied initially, don't let it stop you. Call the insurance company & ask what would you need to do to be accepted. What other options are open to you. They may be able to help you more than you know. Ask your doctor if they know of anything they could do to help with getting it paid. The bad thing for me was that I felt like being obese made me a bad person and I was ashamed to talk to people and admit that. It took me a long time to get over that & I still struggle with it. Keep exploring options.
I have done medical billing for over eleven years and what I can say to you is APPEAL!
First, have your doctor write what is called a "Letter of Medical Necessity" for you which will definitely help in your appeal. If you have no health problems associated with your obesity you will most likely not get this surgery approved. However, if you have any problems such as high blood pressure, diabetes, etc., these need to be emphasized in your letter of medical necessity, specifically how weight loss will improve these conditions. Include copies of your medical records that support any problems you have. Your doctor's office may charge you to do this, but trust me, it is worth it. It could mean the difference of having the WLS or not.
Second, write an appeal letter to your insurance company. In your appeal letter you need to go on at length how this surgery is not for weight loss, per say, but for improvement of your overall health and quality of life. Be very specific with what diets you have tried in the past and any other factors that may prevent you from losing weight the traditional way (diet and exercise). I would recommend writing at least two full pages explaining your personal situation and why you feel this surgery is needed for you.
If you want to PM me, I will be glad to read your appeal letter and give my opinion- I have written thousands of appeal letters over the years!
Send your appeal letter along with your Letter of Medical Necessity and medical records to your insurance company via certified mail, and be sure to keep copies of everything because you would just be amazed at how many things get "lost in the mail" by insurance companies.
Third, be persistent! If your first appeal is denied request a "Second Level Appeal" or a review by the board of medical directors. Ask for a written, detailed explanation of the decision to deny your request. After all is said and done, if it's just not covered under your policy then it's not covered. BUT, many insurance companies will deny an initial request just to try and save money, and many people take the first "No" and give up and do not exercise their appeal rights, so this works out great for the insurance companies. However, if you push the issue and appeal with a letter from your doctor and your medical records showing why this surgery will be beneficial, there is a chance that they will reconsider and approve the surgery. It's certainly worth a few hours and a few stamps.
Dont give up hope yet! I also have Blue Cross Blue Shield. My ice cream flavor of insurance does not cover obesity. BUT!!!!! You DO cover Morbid Obesity. I had to have the doctors office rebill everything with Morbid to get things covered. Call your insurance company and make them cover all angles of the policy. That is what they get paid for.
Hang in there Lots of these and positive thoughts coming your way. get back up to back and take another swing!
I definitely do not have the answers either, but I was denied twice by my insurance company and was getting ready to get a BANK LOAN to pay for my surgery. They week that I was seeking another hospital and surgeon to complete by surgery along with getting the loan I was on my third appeal which was outside my insurance company (that is the way the appeal process worked with my insurance company and the way the level of appeals worked.) That same week I received a call from the insurance company informing me that they "received some additional information from my doctor's office and the decision of denial for my LB surgery had been overturned and approved." .... I have no idea and I did not question it. I just immediately scheduled the appointments with the surgeons office that day and had the approval letter faxed over by 9:00 a.m. the next morning and the rest is history. Like everyone above has informed you everyone is different, but if this is what you need to pursue then I guess you need to do everything in your power to pursue it. It was such an emotional roller coaster of devastation for me, but it looks like I have come out ahead. ... Good luck to you. Keep fighting.
I am sorry that this has to be a fight for you. It's so hard! A few years back I was in a simular position. My DH's ins. did not cover anything that had to do with weightloss surgery or weightloss period!!! I was so mad, upset, crying etc....It seemed very unfair and I still think it is. They called this an exclusion. At that time he worked for a very large office supply store that is nationwide!!
This time around I am covered under DH's insurance and he's working for a very small "mom and pop" style kitchen/bath remodelers!
So, like some of the other posters have said "hang in there" it's hard. And one thing that I would encourage you to remember is.....SOMETIMES NO JUST MEAN "NOT NOW"... Hugs to you!!!
Yes, M.S. - keep fighting! But, assuming that things don't happen, have you considered going outside the country for the surgery? Before you fall on the floor laughing, my daughter told me of a woman she works with (a teacher) who had similar problems and went to Mexico for her treatment. It was MUCH cheaper and she had absolutely no complications of any kind, and has lost over 100 lbs in the past year or so. You would need to do alot of research, of course, but it certainly is a viable option. Good luck, dear - keep after it!!
have you considered going outside the country for the surgery
Sorry, GrammyRN, but I have to jump in on that one- going outside of this country is DANGEROUS!!!
The medical system in Mexico is VERY different than from here in America. They do not have laws and governing agencies that hold physicians and hospitals accountable for their practice or malpractice of medicine. Yes, it may be cheaper, but WLS is not the kind of surgery that you shop around for! It is a very serious, very intensive procedure that requires much thought, planning and post operative care.
If you go to Mexico for surgery and if that doctor screws up there is no recourse for you- there was just something about this on TV about several women who died while having plastic surgery in Mexico and their families found out that the guy who did the surgery was not even a real doctor!
Here in American we have the Department of Health and many other agencies that certify and govern the physicians. It is very easy to find out if a doctor is "real" and if they have ever been charged with a crime- you can google any doctor in this country and get their full bio. In Mexico it is extremely hard to get reliable info.
I could go on and on about this, but the bottom line is- MiddleSister you deserve the absolute very best medical care you can get, and you will NOT get that in a third world country. There are many other options for getting the surgery done like getting a loan from a bank, applying for grants and/or charity, and fighting like h*ll with your insurance company!
Insurance Denial
It's all about the dollar. I think...Sometimes, the wording in the policy allows them to "play" with the meaning of what they will and will not cover. So it looks good to someone buying the ins. until you want to use their money. 
Some thoughts about Insurance Options
