Question by angel: has anyone been denied by caresource for gastric bypass surgery?
I recently got a letter from caresource saying they denied to cover gastric bypass surgery bc they said they didnt feel my health was really at risk i weigh 265 poud now i did weigh 306 at the beginning of my 9 month diet i have asthma my bmi is 43 i have high cholosteral and im borderline diebetic so i felt that i should appeal it.I was wondering if anyone else has had to do the same thing and if so were you approved after the appeal proccess also how does the appeal proccess work ? thanks to whoever can help me out with this
Answer by koogy
I would appeal this decision. Did they support the statement that they “don’t really feel your health is at risk” with any facts? How the heck can they say someone’s health is not at risk if they are morbidly obese??? I don’t work for Caresource but I did work for an insurance company. Generally, when you appeal the decision, your case is reviewed by people who were not involved in the original decision and your information is presented anonymously (in other words, they don’t show your name or any identifying information.) Honestly, when you appeal this (and you should!) you need to point out that the cost of you being diabetic (you either are or you aren’t: the borderline thing isn’t in vogue right now.) far outweighs the cost of the surgery, over time. You can also show that even though you have been on a diet for 9 months and lost some weight, there is no guarantee you can lose more and keep it off, plus your cholesterol is still elevated. Losing the excess weight will reduce the possibilities you will have diabetes (and all of the problems that go along with that) and heart disease.
The hardest thing about the appeal process is that YOU have to do it. You have to be your own biggest advocate if you want the surgery. You will only be out time and a bit of paper. Call the insurance company to find out the process and how you start it. (The information may be in your summary plan description, as well.) The bottom line is you have to convince them that the insurance company will save money in the long run by paying for the surgery!
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