Insurance Denial
 

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?

Thanks a bunch,

Middle Sister

I don't like insurance company policy! :mad: 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.

Angela

Have you seen the documentary Sicko by Michael Moore?

It really has changed the way I think politically. Big drug companies and insurances companies have way too much power.

I'm sorry :(

I'm so sorry you were denied!

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!!

I'm so sorry!

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.

Some thoughts about Insurance Options
 

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.

Don't give up...APPEAL!
 

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.

Good luck!

I'm sorry your were denied! Darn it! These people gave you lots of good advice. An appeals sounds in order to me. Go get them!!!

Appeal Appeal!!!
 

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 :hug: :hug: Lots of these and positive thoughts coming your way. get back up to back and take another swing!

Love
Jen

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!!!

Chrissy

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!!

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!

I have to say that I agree to a point...there really isn't much you can do for follow up care if you live in a different country.

With that said, I have a friend that did her research and found a Dr. that has a surgical resort in Columbia, he was trained and certified in the US and she was able to confirm that...She was in a hotel type setting for 3 weeks and it only cost her 12,000.

Again, the only draw back is, though she hasn't had any, if there were any complications, you have to find someone here that you can trust to help on very sort notice.

The point being RESEARCH YOUR DOCTOR! There have been cases of Drs of all sorts lying about being certified, dodging malpractice and even practicing without the license HERE in the US.

Be careful, very careful and know who you are letting put you in such a vulnerable position.

thanks,

Angela

another big point to consider is the need for follow-up care. many surgeons, especially with the lapband, don't want to care for a patient with an out-of-country surgery. soo, before taking this route [and there's actually an entire industry that's sprung up for out-of-country surgeries!], make sure you can get the EXCELLENT follow-up care that you deserve in your area

Hi Middle Sister.

I work in the insurance industry....I've been one of those customer service reps on the other end of the phone line when you call. Please be assured, the majority of us want to help you in any way we can...but, we are constrained by the way the policy is written.

Here are a couple of suggestions: Is your plan through an employer? If so, check with your Human Resource office to see if the employer has an option for a grievance/appeal through your company. Depending on the type of policy and the administration set-up, the policy mandates might be determined by your employer....ie, they might be able to overide their own policy! If this is coverage you purchased on your own and the policy clearly states, in writing, that weight loss surgery is not covered, unfortunately, you'll most likely not be able to get the surgery covered.

Feel free to PM me if you need some recommendations on actions to take.

Hi everyone! Thanks so much for all the posts. Out of the country, is just not an options I'd ever think about. I have however come to the conclusion that it is over, because I want it to be. I have found that with my stomach problems already, I would be just asking for it health wise. Dehydration is constent with me anyway...I have an ileostomy.
I have been so depressed lately with my weight, I thought of taking my life. However that was a fleeting moment. I have a disease. After a scary three days of a reaction to an antidepressant (overdose by the doctor) I've decided to go to OA and I'll tell you I feel this is where I need to be. I've been depressed for years about my weight, just now am I coming to realize just how much damage I've done to myself. I will still post, but not hear anymore you all are brave soldiers and I wish you all the very best in you weight management. Keep an eye out for my progress. One Day at a Time.

MiddleSister

Middle - congratulations on making a decision that's right for YOU. and i gotta tell you that you are welcome to post here anytime.

i think there's an OA forum somewhere around here. i'll find it and post the link for you.

:hug: :hug:

Middlesister, I feel your pain. When I started the process of LB surgery, I called my insurance company and they told me that it is completely excluded. Meaning, no matter what, they don't cover it. What's funny is the insurance company I had previously does cover the surgery but only after I jump through a few hoops. Unfortunalely, I dragged my feet and here I am. However, I am extremely fortunate because my parents are willing to pay for my surgery, they are behind my decision 100% (practically pushing me onto the operating table, hehe). IMHO, it's a least an option and not completely excluded so it seems like an appeal is in order. Good luck to you!!

OA changed my life Middlesister. (I'm in the middle in my family, too :D) I have talked here about my experiences in OA a bit and would encourage anyone that feels they use food as an Alcoholic would use alcohol to seek out that group of people.

Good luck to you!

Angela

BTW The serenity pray still holds so much truth for me even 15 years after the first time I heard it!