denial?
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ChaniGetsHealthy
Posts: 32 Member
Has anyone initially had their surgery denied (and then later approved)? This is a great fear of mine. I doubt that it will happen considering how overweight I am, but I also have no health issues due to being obese.
Currently I am gathering all of my medical records and proof of trying various diets, which my doctor said insurance will need.
If it was denied, how did you appeal? What did you need?
Currently I am gathering all of my medical records and proof of trying various diets, which my doctor said insurance will need.
If it was denied, how did you appeal? What did you need?
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I was not denied and didnt have any other med issues. I didnt have to prove any dirts, i think it all depends on the insurance0
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I had no problems getting approved. But my insurance simply required a specific BMI for 3 years. When my SIL had RNY 10 years ago, her insurance carrier (who as it happened was also her employer -CIGNA) had an unstated policy of denying everyone at least once even if they qualified under the plan. As an employee she knew this so she appealed twice I think and ended up getting it approved. You should have gotten paperwork when you got your insurance (a plan summary and detail booklet) that is basically a contract. So my advise is to know your contract and be prepared to hold the insurance co accountable to it.
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your clinic/doc usually does all the insurance approvals, preapprovals, and appeals. I have not been denied but they gave me booklet explaining they would if happens. Now I am on hold of moving forward right now to get my blood pressure under control before I get a surgery date, so that is a delay for me but not insurance related. Just up to me, my primary md with meds, and a cardio conditioning on my shoulders daily which is good for me and am starting to like it0
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I went through denial through Cigna. Took about 3 months of fighting it to get it approved.0
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I got it approved initially but then switched hospitals because I didnt feel comfortable having that hospital staff doing my surgery (they were HORRIBLE with paperwork and knowing my insurance requirements, very incompetent). So after switching hospitals I thought it would be easy to re-approve since I had everything so organized (because I had to due to the other horrible hospital) and told them exactly how my paperwork was supposed to be presented to the insurance. Of course they didnt put it together like that and so it was denied. It took about 2 months to straighten out.
Biggest thing to know is to keep your own records of everything. All the documents you are supposed to have for the requirements, keep a copy for yourself. You are the only one in charge of your health. So if the hospital messes up, you can fix it yourself. This is the biggest thing I have learned after spending a year prepping for the surgery. I had a huge binder I took to all my appointments. I would keep all the doctor appointment summaries and test results. Sometimes they dont offer those automatically so I would occassionally have to ask them specifically for these things each time. But its better to do this as you go along instead of trying to compile it all last minute because it does take weeks sometimes for offices to transfer records and approve record transfers etc.
Dont worry, just start taking control and then you wont have to worry so much because you have everything incase something goes missing last minute.0 -
Oh and the appeal is super easy. For me (United HealthCare) it was just filling out a simple appeals paper and resubmitting the specific reason why it was denied. The denial letter spells it all out. Of course its always good to overload them with documents and proof in the appeal to be on the safe side.
Personally mine was denied because they didnt think I had the 6 months of monitored diet. I had the first 2 done with my family doctor then the next 4 with my nutritionist but it was initially sent with just my family doctor 2 appointment summaries. The hospital had a worksheet you can fill out for each month you go to the doctor and have your doctor sign it and stamp it with their office stamp. So I pre-filled it out for my doctor so all he had to do is sign it and stamp it. I had all my appointment summaries so I knew what my weight and blood pressure and any specific notes he wrote about that appointment so I could fill out the paperwork before going to him to sign it. I happened to see him practically every month so it worked out.0 -
My husband and i have Aetna. I was approved with a 35 BMI due to health problems and he was denied. He appealed and was denied a 2nd time. He was told to wait 6 months and try again. His paperwork will be re-submitted again in Feb. (we both did 6 months of classes etc and had to pay for that out of pocket)0
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I also did not have health issues do to being obese, but my Primary care doc wrote a letter about why they recommended me for the surgery due to the risk of developing issues based on my obesity, which was included in the package submitted to insurance by the WLS doc.0
