Getting approved

Mar 04, 2011

I started my journey last May 5/2010 when I made my first appointment. After 5 months of appointments and tests I had a surgery date of Oct 12, 2010. I started the liquid diet and 6 1/2 days into it my surgeon's office called and said my insurance did not send authorization. All along the way I questioned are you sure I qualify and was told yes, you have a BMI of 36 as long as you do the program. (I have multiple co-morbidity's) I also had great difficulties with my primary he wrote the surgery clearance did the tests and I had to fight to get him to write my letter of medical need at the very end. I found out our plan  penalizes doctors who recommend too many surgeries.
My insurance does not specifically state a time line that you should be above 35 BMI for 3 consecutive years prior to surgery, but that is the excuse they used for denial. They stated on telephone that a group reviewed my request and it is standard practice that one must be obese for 3years. I appealed and they stayed with the same statement. It says I now qualify but would have needed to be > than 35 for 3 year to met plan criteria (which does not exist). I reported them to US department of labor and ERISA just to get a denial letter. They were so arrogant they just kept saying you don't met plan criteria and we don't even have to respond. It took over two months 12/2010 just to get appeal letter.
  I have a 24 year history of weight issues but have lost weight as much as 80lbs and eventually regained.
Today I have added a second insurance and have another appointment 3/10/2011 with the surgeon.
Today my BMI is 40.2
The new plan is Blue cross of Florida which does say one needs to have a 2 year history.
I still have my primary which is administered by Meritain which has no time limit in plan criteria. I believe they should pay!!!!!!!
Frustrated.......
 

2 Comments