Input PLEASE (Desperate)

I have BCBS of TN. My insurance does cover WLS. I am 160 over weight & bmi of 48. I read & understand that if you are 100 lbs. over, twice the ideal weight OR bmi over 40 you don't have to have co-morbidities. So, why did I get denied for Not Medically Necessary? Has anyone had this problem w/BCBS that has any input. My surgeons do not fight for us after a denial. I am on my own. They did tell my surgeons office my psychological evaluation did not consists of the IQ test or mmpi test. So, I am having another one this Fri. They said they will re-admit it for reviewing on my surgeons request. I am afraid it will not make any differance. Thanks Ellen

Ellen, I'm not sure why you would be denied from BCBS sounds like you meet the standards. Just wanted to offer some encouragement and adv you not to give up!! Maybe this time witha good psych eval and letter of recommendation from your PCP everything will go well and you will get an approval. Just stay positive. You can do this!! {{ Huggs}}

They deny it because:: THEY CAN. And they will, and they don't want to pay. Give em heck. Call them everyday and ask any and every question. Show them you are not giving up. Fight it yourself. Get a copy in writing of what they require. type it out. Write an appeal to counteract every thing they have said. Say, "Your criteria states that I must be 100 pounds overweight. According to my medical record from PCP (name) I am approximately 160 overweight." Do these kinds of things and provide the medical records. Ask your pcp to provide a letter in writing stating, "this patient has lost 10% of her ideal body weight...this patient..." yada yada whatever they want. BC does not like to review medical records. I swear I dont think they reviewed my 110 pages or else they would have found everything they needed... they wanted one letter with everything in a nice neat package. But if your doctor doesnt do it for you, you will have to do it. I would say find another surgeon who will fight it for you. They must not want the money or else they would fight it.

I have BCBS of TN but mine is the state policy....i do know that you have to have 5 years of medical records showing that you have been obese for 5 year, you have to have 6 months of documented weightloss by you PCP, and in the regular BCBS of TN (not the state plan) you have to loose 10% of your weight before they will approve it, i had my psych eval at the Evelyn Frye Center and they do the IQ and MMPI test when you go there, it is $295.00 but that is down from $600.00, i went there because that is who Centennial told me to go to....i hope this information helps

Here are the reqs for BCBS TN http://www.bcbst.com/MPManual/Bariatric_Surgery_for_Morbid_Obesity.htm You also might want to call the customer service # that is found on your insurance card and ask for the requirements needed to prove medical necessity for bariatric surgey. Hope that helps! april

Thanks April, that is the exact page I have copied and high-lighted to mail in. thanks

Ellen, Do not panic. When I went through the insurance process I was told the same thing, "Not Medically Necessary." After talking with a very nice rep at BCBS she stated to me that is a standard form letter they send out. Even if they are missing just one document they issue this STANDARD FORM LETTER. They do not go in and list on a letter what exactly they are missing. When you are on the phone with them, ask the rep to tell you exactly what the reviewer noted that was missing documentation from your file. They will tell you and you can get to them what they need. There is no appeal process over this it is just getting them all the required documentation. In my case my WLS center had faxed all the required documents but some of the fax was missing so instead of letting us know some of the documents did not come through they just mailed a Not Medically Necessary denial letter. The documents were re-transmitted and I received my approval letter soon after that.

Julie, that makes me feel better because that is exactly what happened. My psy. evaluation was incomplete and that is the letter I received. When the surgeons office called it was because of the missing IQ test. The girl I called didn't tell me that. Did you have any comorbidities? Thanks Ellen

FYI..Thay can NO LONGER ASK FOR IQ test!!!!! But mine asked for a Nut Eval, which they did not before!!!

I was under the impression that they couldn't ask for an IQ test either but at the end of the day, I would do whatever I had to do to get the approval. And I wouldn't worry too much, Ellen. I really do think that your denial is solely because of the psychological exam not being what they require. If you get denied after that, FIGHT IT FOR ALL YOU ARE WORTH because YOU ARE WORTH THE FIGHT. I really will be surprised if you are denied though. I can hardly wait till Friday for you! Hang in there! Melanie