First Insurance Denial - Please offer some advice on how to continue

Hi. I am pretty new to this board but have been researching WLS for about 8 years.

I have decided on RNY, I selected a surgeon in Utah (I am in Idaho and I don't have any faith in the doctors here). I sent them my initial paperwork and they just got back to me saying BCBS said it is not covered as it is an 'elective surgery'. Now I have reviewed the copy of the policy they sent me when I signed up and it states that it IS an exclusion EXCEPT when deemed medically necessary by a physician, the patient has a BMI over 40 and a comorbid condition.

I have a BMI of 48.3. I have GERD, high blood pressure and am 'severely insulin resistant' (my blood work was literally point away from calling me diabetic), joint & back problems and most like sleep apnea.

I have a new physician who is supporting my decision for surgery. He and I have only met twice but he agreed and gave me a referral to this surgeon. He sent my medical records to the surgeon.

What can I do?? It states in my policy that there is a way to have this covered. How can they deny me?!

I appreciate any guidance. I am feeling pretty dang discouraged right now

Insurance companies can make mistakes. There should be a process outlined in your policy documents for appealing. It might have very quick deadlines, so be sure to look it up as soon as possible and follow the process to appeal. Since it sounds like you absolutely fit their criteria, your appeal should be successful. You might also try contacting your insurance's customer service to see if they can give you any more details to see if there is another factor in the denial, such as going out of state.

Edit to add: Have you met with your surgeon yet? Your surgeon will have to submit the certification of medical necessity, so if you haven't met him or her and are just submitting paperwork on your own, that might be the problem.

Call your surgeon.  Mine handled all that for me.

Best wishes

Thank you for your replies. It was the surgeon's office that told me they said no and offered to let me pay for it myself. I just got off the phone with BCBS and IT IS covered with the comorbid conditions and the BMI. The surgeon's office told them that it was ONLY for weight loss and never mentioned my comorbid conditions!! I am pretty ticked off right now, why would they do that! Am I being sensitive because right now I feel like they could really give a flying crap on my getting approved or not.

They probably are just a bit less familiar with your insurance since it is from out of state. It sounds like they will be able to get it all sorted out, though, so that is great! 

So get copies of your records, showing your comorbid conditions, and submit those to your insurance company.

It sounds like they need to resubmit the claim. You qualify hands-down. Your comment about Idaho doctors is intriguing to me. I just had my WLS here in Boise and both the doctors in the practice have very high ratings and very low complication rates? Plus the hospital in Boise is a Bariatric COE. Either way, good luck on your journey!

I am outside Idaho Falls, so on the other side of the state. Salt Lake City is actually closer to me than Boise. The Idaho doctors I am referring to are the local doctors who do this surgery (closest one is Blackfoot) and I have known two people who have died after having this surgery while under their care. So I will go to Utah. My dad had RNY in Boise and he said they were fantastic! I apologize for painting with to broad of a bru**** was not my intention.

I emailed them again last night, detailing that I spoke with BCBS and it is an exclusion unless you meet certain requirements WHICH I DO MEET!

This is what he sent back to me:

"One of our insurance specialist, Caitlin, was the one that contacted your insurance company to verify your coverage.  She feels strongly, after talking to Peggy at BCBS of ID, that your policy does not include weight loss surgery as a covered benefit.  That being said, you certainly have the right to proceed with the authorization process."

I do not understand what the problem is here. I have verified that it is covered, if you meet the requirements. Why are they showing NO interest in pursuing this?

I don't know.  Sounds like they aren't interested in your business for some reason.  I'd consider finding another doctor that does want your business.