Denial rcvd..

Well I got the call that I'm denied for my surgery that is set for January 21. I have just completed my six month supervised nutrition/diet course at my surgeon's office. BUT now the insurance company is saying it has to be from my physician. *&"#@%%**)-@"# Are you serious?!?!?!! I don't even know what to do now. I'm so upset.

That may be appealable, but if not - find out exactly what to do....how often your doc has to document, etc, and get it done.  This is only a setback.  It could be worse.  I got started on getting my DS, and was offered a promotion.  I didn't want to take off right away, so I waited 6 months to settle in before addressing it again.

Does their written criteria specify it has to be with a physician?  I'm guessing you weren't aware of that?  You can ask your surgeon's office if they have any ideas, but if the insurance company's written criteria says it has to be with a physician, I'm not sure what will happen.  You can appeal and ask them to approve it anyway, but if you didn't follow their requirements, they may not approve it.

So your surgeon is not a physician? Just because he isn't your PCP doesn't mean he isn't capable of doing the same thing as your PCP would have done. And was probably more detailed than your PCP would have been.

 

That was my question to the lady handling the precert at the surgeon's office.  She didn't give me an answer and asked if I had any documentation from my pcp of weight loss attempts.  Basically beat around my questions but I'm going to call back tomorrow.  All this broke today so I just have been in utter shock but tomorrow is a new day and I'll be on that phone.

 

 

The surgeon’s office also told me my six month program would be done with them and that is what the insurance required.  Now the insurance department at the dr’s office calls me today telling me otherwise.  She said the nutrition and exercise program had to be supervised and monitored by a physician working in cooperation with dietician/nutritionists.  Well I thought that’s what I was doing for the past six months by going to the bariatric doctor and seeing their nutritionist and doing the monthly meetings, weigh-ins, keeping an exercise journal and all?!?!?!  I’m very frustrated.

I will appeal but in the meantime I already made an appt with my primary.  I explained to my primary why I'm coming back in again and they are not understanding why, when they sent me to the bariatric for the diet program and all. 

You need to call the insurance company and ask (demand politely) to speak to a SUPERVISOR. Ask her to send you a copy of the very requirements she is looking at. Tell her you have spent the last six months doing a supervised diet with a PHYSICIAN and the nutritionists in his office.

 

Insurance companies are required by LAW to use very specific,understandable to the average person language in their policies.

 

if the written policy doesn't state the 6 months has to be done by your primary care physician ,I mean explicitly state done by your PCP,then they CANNOT  deny you for doing it at the surgeons office.

T

ell the supervisor that you are aware of all these legalities and politely demand that she approve it on the spot or prove why you are not in the right according  to the written policy.

Good luck and keep us posted.

I agree with Southernlady  I would certainly appeal this based upon the argument she has provided.

Also, one of the things I do for a living is appeal insurance denials, so I would advise you to do a couple of things.

The first is that I would not ask, but rather demand that they approve your surgery immediately based upon the fact that your six month diet was supervised through a physician's practice. 

In addition, keep the appeal strictly related to medical necessity.  Where a lot of folks mess up on their appeals is citing their reasons for the needing the surgery to be something other than strictly medical, such as wanting to be able to play with their kids.

Insurance companies don't care whether you can play with your kids.  They are not going to grant a surgery for any reason outside of strictly medical necessity, so keep the focus right there.  Keep anything personal out of the mix, or this could get you denied.

Good luck!!!!

Thank you DebsGiz for the info.  I will do just this.  I have a list of medical issues so this will be my ammo.

 

I appreciate all the responses!

Good luck!!!

Please know that my fingers are tightly crossed for you!!!

Be a pain in the ass.  Let your insurance company know that you're not going away until such time as you get what you want and oftentimes they'll approve just to get you out of their face.  Be respectful and very firm.  Tell them exactly what you expect and demand it. 

I cannot tell you the number of appeals I have filed, based upon nothing but BS that I've pulled out of my rectal orifice, that I've won.

My stance has always been if I'm wrong in my assertions, the insurance company has to prove it; otherwise, they'd best pay...

Again, good luck!!!!