Denial Molina

Just got my denial from Molina.  They said I did not meet the guide lines.  What?  They said I did not have any co-morbidities, well, my bmi was  41.8 and I have high blood pressure, high cholesterol, high blood sugar, etc.and I don't need co-morbidities with a bmi over 40.  I had to lose 12 lbs pre surgery for the surgery center and it brought my bmi down to 39.6.  I'm wondering if that was what did me in.  They also said I never had any pulmonary studies done when they had to pre-auth the Dr. who did my pulmonary studies!!!!! I actually had all of the material sent in twice.  Once via the mail and once via fax with a confirmation.  How do you deal with Molina and the bmi issue if the surgery center needs you to lose 5% of your weight pre surgery?  I am going to go ahead with an appeal.  This really stinks as I have been working on this since January and thought I was finally near the end.  Any one have anything similar happen and any advice?

Thanks, Tami

 

 

This is common with most ins co's.  They have a hard time getting their act together.  Sometimes it's the MD office and sometimes it's the ins co.  Just appeal it.  If that doesn't work (and it should) file a complaint with your state ins comm.

I don't have Molina, but it sounds like you have plenty for an appeal!  Good luck!!!!!! 

 

Sorry to hear you are experiencing this.  Don't give up, definitely appeal the denial.  Here a link to some threads discussing appeals.  We hope you find this helpful.

http://www.obesityhelp.com/search/action,search_oh/?q=appeal ing+a+denial&cx=000946886326336472648%3Ae-vpeg4uyxw&cof=FORI D%3A9

Thank you for the replies.  There are some very informative appeal letters out  there!  I didn't realize just how crafty these insurance companies can be, all in the name of money. After 6 months on a diet and exercise plan that is part of the insurance company and surgeons requirement, how do they not expect you to lose weight when they expect you to lose weight?  I guess I just assumed I went in with a 41 bmi and that is what it should have been looked at as, not what it was after I followed all of their requirements.  I feel like I am being penalized for following directions.  Well I am all geared up to write a heck of an appeal letter and send them every dang piece of required material and then some. I worked way too hard for this, not giving up now!

Thanks again,

Tami

Sounds like there was a problem with the packet they received. I get the feeling that the folks doing initial review are not highly skilled, and they will not connect any dots for you if the info is not crystal clear for them.

You are sure you qualify per your specific plan's contract conditions?

If so, it sounds like with some clean up of your submission packet you can successfully appeal.

Good luck!
Laurie (stuck in appeal hell for 5.5 months - it is winnable!)