Starting the appeal process for insurance and I'm overwhelmed!

Wow!  This is just almost more than I think I can handle.  I work in the legal field, as a court reporter, and was hoping that putting together this appeal letter to Blue Shield HMO wouldn't be as scary as it is.  I've dragged my feet now for about 7 weeks since I received the denial letter and I know part of the reason for that is because I just don't know where to begin.  My friend Michelle who had her DS surgery in May was super nice and forwarded me a copy of her appeal letter, which I think is great.  However, it's so professional and technical that it goes right over my head.  I believe my letter needs to be something more on my level that I can understand, especially since I'm supposed to be the one authoring it!  LOL  Anyone have some ideas they can offer me.  I'm feeling super down right about now!

Thanks,

Christy

IMHO, the most important thing about an appeal letter--besides the author's being able to understand it--is that you appeal the grounds upon which they based their denial.  So, also imho, someone else's appeal letter will do you no good, unless the two of you were denied for the same reason.

So...why were you denied?  And just for fun, why was Michelle denied.  (Her appeal would have to have addressed that issue or they wouldn't have changed their minds.)

The reason they state for denying it is "lack of medical necessity" and the fact that the care needs to be managed in the Desert Oasis HealthCare network (my group).  Since my "morbid obesity" can be treated within DOHC's network and does not meet the requirements for an out of network authorization, (hence their approval of bypass) the service has been denied.

I just reread Michelle's appeal letter and her two reasons for being denied are exactly the same as mine, lack of medical necessity and the out of network service could be performed in network.

Okay...so they have agreed that you need wls.  That's step one.

Next...I'd come up with reason why you are not a good candidate for the procedures they offer.  Is that what Michelle did?

(What's your BMI?)  If it's over 46, you have a good start fighting off the suggestion of a band.  Do you have other medical conditions that require that you use NSAIDS?  Like arthritis or fibro or other things that need pain relief? 

And, since Michelle's appeal worked...can you copy it leaving out her name and other personal stuff and PM it to me or share it online?

Maybe you just need to reword it so that it sounds more like you...and maybe we could help with that.

Sue

  

Send me your email address in a PM. I'll send you the "book" I wrote for my revision. It won't all be pertinent for you, but cut and paste whatever you need/want or look at the format. Ms. Cal cu Lator is (of course) correct- you must refute each of the ins. co's points. I used a bullet form for my letter which is, IMHO, the clearest way to refute their (asinine) points. No one can really do this for you, but you can for sure use the expertise of everyone on OH! BTW- the appeal letter my surgery coordinator wrote for me was one page and it was just a form letter. It was a piece of crap. No wonder I was denied!  Definitely do it yourself!

Well f'ing hell - I had to click on your listed surgeon's name to figure it out, but you live in CA!  The CA DMHC almost without fail overturns denials of the DS.  But you have to play the game - you have to file your appeal, rebutting all the incorrect reasons they give, and they will deny you again, then you have to file another appeal (usually a slight variation on the first one), and they will deny you again, and then (having exhausted your internal appeals), you get to appeal to the DMHC for an IMR (independent medical review) which almost always results in the denial being overturned and the insurance company being ordered to pay for your DS.

BUT - you FIRST need to self pay for a consult with a real DS surgeon.  I'm assuming you're in the high desert area of SoCal - I would suggest you contact Keshishian and get a consult scheduled.  Take the denial letter with you so he can write his LOMN with that in mind.

You shouldn't file the appeal until you have his LOMN to back you up.

Thanks everyone for helping. 

Sue, my current BMI is 44.8, however, when I started this process, 11 months ago, it was 52.3.  I'm down 55 pounds in a year.  I don't take NSAIDS for any condition such as arthritis.  I do take Allopurinol for a problem I had with my fingers swelling.  I guess I had excessive uric acid.  I have high blood pressure, sleep apnea, and in February my PCP told me I had pre diabetic numbers in my blood work, however the May blood test showed them down some.  My mother is diabetic and has been for 42 years.

Diana, thanks for the advice.  I did read your information regarding appealing insurance company decisions awhile back.  I had talked to Michelle about it also and she did tell me that the DMHC was very pro DS.  So I am hoping that will work in my favor.  I hate having to jump through the hoops though.  I'm copying  things out of Michelle's letter and making it my own.  However, she does have the need to take the NSAIDS, which I think was a plus for her, and I don't have that.

I did try to make an appointment with Dr. K's office for the initial consultation, however, Lupe, the one I always speak to when I've called there or actually shown up in person, said that to have a consult with him and pay cash for it means I'd have to go cash the whole way.  I think that's ridiculous however every time I talk to her about it, she says that is how it has to be.  So, I don't know how to get around that.  I've already attended two of Dr. K's group sessions.

Here's my private email if anyone would like to share any thoughts or ideas with me.  It's [email protected].  Again, everyone who has responded, thanks so much!

Christy

Christy, the info Lupe is giving you is not correct. I would have thought by now his staff would know the drill, as they have had other patients who had to fight denials, but bottom line, you pay for the consult up front, get Dr. K  to write a LOMN, etc, do your appeals, etc, and if/when you eventually win, the insurer has to pay for your DS. You may still have copays and whatever you would have paid if he were in-network, depending on your coverage, but they pay what they would normally pay for an in-network surgeon.
    You would also still be stuck with his "program fee", which no insurer pays.

I will also send you a pm.

Larra