How are people denied?

I haven't finished everything I need to do to be approved by my insurance, so maybe I'm missing something. But if you fill all of your insurance's requirements as stated in your policy, how can they then deny you? I don't get it?  I called my insurance and had them verify exactly what I needed to do and had them mail me the 37 pg section of the policy that pertains to WLS.

 

So, the people being denied, are they not meeting the requirements, or are they technically supposed to be approved and the insurance company is messing with them?

In many cases, it's a matter of the insurance company not receiving all the documentation they need.  for instance, I've known a couple people that were denied because the surgeon's office failed to send proof that the person had a psych eval or met with a nutritionist or something like that.  The surgeon's office then send the necessary documentation and the surgery was approved.

I've known a couple people whose insurance policies required them to provide a five year history of being obese, but they hadn't seen a doctor every year for the past five years so they didn't have five years worth of records to submit.  In at least one case, they were initially denied because of that but appealed and provided photos that were date stamped and you could clearly see in the photos that they were very, very overweight, and their WLS ended up being approved.

If you meet all their requirements, they have to approve you.  You've paid for the insurance policy, now they have to provide the coverage you've paid for.

The whole insurance thing is so nerve racking. I just finished my six month stint with nut and exercise plan and all testing etc. my paperwork was submitted Monday and now I just wait. Good luck and just hang in there. Will your surgeon's office be submitting your paperwork when your done? I hear that they are usually good at getting everything put together right.

Yes my surgeons office will submit the paperwork. But you can bet I'll be doublechecking everything they do. One way or another I am having the surgery.

My insurance company denied my claim and my subsequent appeal.  I have a PPO through United Health Care and WLS, including VSG, which is what I got, is covered.  However, while I hovered around a BMI or 40-41 for the last 6-7 years, I'd temporarily lost weight (which of course I gained back) on a couple of diet attempts.  For that reason, I didn't have documented, consistent weight over 40 BMI, which was the reason for denial. 

We tried everything too - I sent photos and an explanation and my surgeon even spoke with them in the appeals process but it was still denied.

"Luckily" it turned out that I had a Hiatal Herna which was covered by my insurance.  My surgeon fixed the hernia and did the sleeve at the same time so pretty much everything was covered except an additional surgeon fee and some extra anesthesia, which is insignificant to the cost if I had to self-pay for the whole thing.

The weird thing is that the United Health Care nurse keeps calling me to discuss my health and weight loss surgery.  At first I was super irritated that they all of sudden cared when they denied me but now I figure any advice they can offer is great.  It's great to get additional information from them when my Dr. is busy.

 

I have UHC & the nurse will call you every month to check up on you.

I see - I wondered about why they were calling.  The nurse was actually helpful in some ways.