I was denied Too :(

[Lynn Smith]

What do I do now? Please help!!!!!!

 

[Whit]

How? Give us some info. A little background. How do we know what to comment about or help with?

 

[Spiky Bugger]

Denied...because...?

 

[JackieOnLine]

Hi Lynn, welcome to the board. please give details!

 

[southernlady]

Lynn

It would help to know these things:
1) Who denied you? Insurance or PCP or Surgeon?
2) IF insurance, which insurance company/in which state
3) Have you received your denial letter?
4) The stated reason for the denial.

 

[Lynn Smith]

I was denied by insurance. Medical Mutual. I am using Dr. Sudan in NC even tho at the moment I live in Ohio. My out of state coverage is firsthealth. I did receive the denial letter. It said I was not using multiple medications to treat my blood pressure which I have been for months. Insurance also said that they could not read the Psychologists report. Also that is was unclear if there were physical problems that interfered with daily functions.

 

[Larra]

There are some basics for you to do here, though you are somewhere in the middle of the process. First, get a copy of your insurance policy and read it yourself, particularly the section about coverage for bariatric surgery. You are entitled to this information, either on paper or on line. Do not rely on info some low level person who answers the phone tells you, you need to know for yourself where you stand with your coverage and what appeals rights you have.
Next, get ahold of your medical records. Again, you are entitled to these, though there may be a small fee for copying them. You will then have documentation of your blood pressure multiple meds (though I'm not sure why this matters, because we don't know the details of your coverage for bariatric surgery) and your own copy of the psych report. If the report is in fact not legible, insist on being provided a legible or better yet typed report.

You need to know what your insurer requires of you to have bariatric surgery, know your bmi, your comorbidities, your past weight loss efforts, etc etc. Without this information, we really can't help you and more importantly you are not able to help yourself. But at least getting those records and knowing your policy and appeals rights would be a big start.

Larra

 

[DianaCox]

What is your BMI? A BMI over 40 per se qualifies for bariatric surgery - you don't have to have ANY comorbidities.

 

[Spiky Bugger]

I'd chime in, but you have just been answered by two women who help people get coverage for a hobby!! They are absolute pros...just do exactly as they say and you will get the best results possible.

So I will just recap.
Find a copy of your policy...it's probably online.
Find the section on bariatric surgery and read the whole LONG miserable thing.
Know your BMI.
Just go step-by-step...you'll get there.

Sue

 

[DianaCox]

By "the policy" is meant your Evidence of Coverage document - should be about 80-100 pages long. Your HR department has to provide a copy, preferably as a searchable PDF.

 

[Lynn Smith]

I have the PDF. I have requested my file and am waiting for it to come. I am also going back to some of my doctors and asking for them to write more extensive letters. High blood pressure isn't considered a comorbidity?

 

[Spiky Bugger]

I have the PDF. I have requested my file and am waiting for it to come. I am also going back to some of my doctors and asking for them to write more extensive letters. High blood pressure isn't considered a comorbidity?

Depending on your policy and your BMI, you may not need any comorbidities. No need to spin your wheels to prove the existence of something you don't need.

What's your BMI? That will be hugely important.

https://www.nhlbi.nih.gov/guidelines/obesity/BMI/bmicalc.htm

Have you tried to find your insurance company online?

 

[Lynn Smith]

It was 41 but then I got sick with pnemiona. Took me two months and three rounds of meds. I lost a few pounds during that time and now I go between 39-40 depending on the time of month.

 

[Spiky Bugger]

Okay then...In the past and in my experience, many policies list a BMI of 40 OR a BMI of 35 with one or two comorbidities.

I would spend more time finding EXACTLY what your policy requires and less time bugging doctors. You may need them later and don't want to wear them out too soon!

If you are that close to a BMI of 40, maybe all you need is to eat some potato chips before your next weigh in.

It SOUNDS like your insurance wants to argue about your compliance with meds...and that may not be an issue at all...they may just be acting like they often do. Or maybe your BMI was 39 on the documents they were looking at.

And the women who know this stuff will probably need the EXACT WORDING of the denial to effectively help you.

Sue

 

[DianaCox]

It was 41 but then I got sick with pnemiona. Took me two months and three rounds of meds. I lost a few pounds during that time and now I go between 39-40 depending on the time of month.

Did you establish your starting weight at the doctor's office, preferably with your bariatric surgeon's office?

High blood pressure uncontrolled by medication is a comorbidity.