Denial Letter

TO START I AM 260 POUNDS I AM 5'4 AND NO I DONT HAVE NO COMORBIDITIES BUT I THINK IF I DONT LOOSE WEIGHT I MIGHT END UP HAVING MEDICAL CONDITIONS IT RUNS IN MY FAMILY AND OKAY I WENT TO THE AETNA WEB SITE AND YOU HAVE TO MEET EITHER CRITERIA THERE IS A SIX MONTH AND A THREE MONTH REQUIRE PROGRAM BUT I ALREADY WENT WITH A NUTRITIONIST FOR ABOUT 4 MONTHS WHAT SHOULD I DO

I got your message and I'll respond to that too, but I want to put this on the board so that others can see who are also in the same boat.

Call your HMO and explain your situation to the customer service person.  Tell them that you want a copy of the medical criteria that qualifies someone for surgery.  THEY HAVE TO PROVIDE THIS TO YOU.  Do not take 'no' for an answer.  If the person says they don't have it or something lame, ask for their boss and DO NOT BACK DOWN.  Ask them to FAX it to you so you have it in print.
Depending on what the criteria is will determine your next step.  You may not have 2 or more comorbidites....although I think just having a BMI of over 40 is enough. (I'm not sure)
If it is because they want you to see a nutritionist, go on a diet, or something lame like that THAT IS B.S.!  Under the law in California you do not need to do these things and HMOs get away with it because patients do not know the law and never even know they can fight back. 
You can write your own letter of medical necessity, check out the insurance boards for ideas....I know there are even some samples floating out on the internet that you can copy and then fill in the data that applies to you like your weight and BMI etc.....   If they deny you, can go to the staet of California's DMHC. (see my recent top post on the board about this.)
I know you're sad, but it's not over.....you will just need to push a little harder than most to have surgery. But it is possible! 

Check my blog. My appeal letter is there. Copy, edit and use it. Send it certified mail to your doctor, your medical group, and the insurance. My doctors office stalled and "forgot" to include stuff, or use the correct wording until I sent this letter. Good luck!