Trust me, he went to bat for me in the peer-to-peer. His medical assistant told me he was livid and he never does peer-to-peer because he’s not confrontational. Being a nurse myself, I trust them. And he told them losing weight will help overall with health, but won’t change the knee condition of my knees.
Per the surgeon, I may be the first person they’ve ever had denied for BMI via insurance, but I certainly won’t be the last. And he now knows that they’re going to have to inform patients they will need to be 40 or below for their knee replacements. He also said in investigation that more companies have slid in BMI requirements in 2018 for elective surgery. I guess it’s the new condition of not being able to deny folks insurance/charge more for pre-existing conditions, so now they’ll put in caveats to deny treatment/service.
I started my pre conditioning PT today and am down another 2 lbs. I just keep on trucking. PT is shocked I was denied. At first they were looking at me like I was crazy because I have leg strength until they measured me and saw the condition of my knees/pain I’m in. I’m going to look into water aerobics too to help push the last 10 lbs required for surgery. The issue is being I’m a 12 hour nights nurse, the classes fall in the middle of my “night” sleeping.
As far as the calculation, I’m definitely irritated that considering they completed a Wellness profile on me in February stating my correct height and weight at that time, that they took some random weight from an ER record (where I fell on my knees at work) for 2013. No one measured my height, so I would assume ER defaults for a woman at 4’11”.
I haven’t heard back from the insurance re: internal appeal and it was two weeks this past Tuesday. Another physician, who is not an orthopedic surgeon, feels they will overturn the decision. At this point I can’t sit back and wait to hear so I’m doing what I need to do.
United States
