Help, don't know what the next step should be!

BABY-LYN · 08-28-2008, 08:23 PM

I was denied by Empire - BCBS yesterday because my BMI is only 38.5 with no UNCONTROLED comorbitites. But BCBS never said that that was there requirements to meet when i called the to see if they would cover it.

the Insurance person that I could call for reconsideration, have a peer reivew or appeal. I don't know what the reconsideration or a peer review involves. do i need to call the insurance company to handle this or what?

I called the doctor's office to talk with the person who handles the insurance but they haven't been alot of help. she talks forever to return calls and then we just play phone tag. she said that she would talk with the doctor but didn't know what he would say. and that it wouldn't be until tuesday. since it's the holiday weekend.

i don't know if i should just go and start a appeal process? is BCBS just trying to get out of having to cover this? What do i do next?

oh, the insurance person said i only had 10 business days to take action? what's that deal ???

Do i just gain the 10 to 15 lbs needed to have the surgery? will the insurance then cover it then or will they give my another hoop to jump through? I hate the thought of having to put on even more weight. i feel so big and uncomfortable already.

Any advice ?

Kalipso2 · 08-28-2008, 08:39 PM

i'm not sure how many people have fought insurance companies and won...

me... i didn't want to take the time and money to fight. once i decided to have the surgery i wanted it as soon as possible.

sometimes being self pay moves the process along VERY quickly.

good luck if you decide to fight!

Smartiegirl · 08-28-2008, 09:04 PM

Hi! I know everyone's insurance is different, but when I was at my information session the bariatric clinic I go to really stressed the fact that MANY people are denied at first. A guest speaker told of how he was denied FIVE times before he got approved. The number one thing they stressed was DON'T GIVE UP! I would have hoped that the person who handles the insurance would be more helpful. I'm sorry that is happening to you. Don't give up, keep us posted on what transpires.

Carramia · 08-28-2008, 10:01 PM

I had surgery in Mexico for 1/2 the price that it costs in the states because my insurance wouldn't cover the cost. I got the GREATEST care and Dr. Huacuz was so nice and he actually cares! I would reccommend him to anyone. His staff was so nice and caring and his Clinic was super clean. It's worth looking into if you want it. If you want to know every detail I will be glad to share.
Good luck!

BABY-LYN · 08-28-2008, 10:09 PM

i just really feel like BCBS is trying to get out of having to pay for it. what have others done to get an approval from a denial?

JaimeSTL · 08-29-2008, 12:53 AM

I also have Empire Blue Cross. I was approved the same day my information was sent to them. They are very friendly about it, gave me no problems at all. I really doubt they are just trying to get out of paying. Here is a link to their requirements, it might help you.
SURG.00024 Surgery for Clinically Severe Obesity

4Emma&Erick · 08-29-2008, 10:18 PM

I've been overweight for 15 years and was frustrated that insurance wouldn't cover the procedure at a BMI of 38.7. The simple answer for me was to gain the weight. It literally only took me 10 days to get to 40 BMI. I ate foods with sodium and drank a lot of water on weigh in day.

The doctor said I was a great candidate for this surgery and the insurance part is sometimes a matter of numbers and calculations.

If you are really close and want it bad enough...just go for it.

Once the paperwork was submitted 40BMI I got approval in less than a week.

BABY-LYN · 09-04-2008, 09:25 PM

Update on my status ...

Denial reversed - I'm APPROVED!
I called my insurance company last Friday and was able to talk with a very helpful employee. He very clearly explained why I was denied. My paperwork did not include any of the info on my high blood pressure. I got it sent over to the surgeon's office and they faxed it over to BCBS.
And today I was approved!

i'm so happy! i went to see the pulmonolgist yesterday. i have my breathing test done this Saturday. Then i need to attend my 3 hour class, have an ultrasound on my stomach and attend a support season. Not to much to do, LOL. I hope to possibly get my surgery date soon.
i would love to have surgery the first of October since i don't have to travel then for work.

NFaith · 09-06-2008, 11:21 AM

Congrats!!
Congrats to You!