need help-appeal

Hi, just wanted to know if anyone could give me some information or help with what has happened. Here goes, I have been on a supervised weight program with my pcp for over 18 months and my dr who was going to do my surgery, Dr. Rehnke, submitted all my paper work to my then ins. Healthease (HMO for Medicaid) in mid December, on January 3rd received my letter from ins. that they were denying me due to the fact that "The clinical information submitted and reviewed does not meet guidelines for such surgery. A physician's summary letter is not sufficient documentation that the member participated in a physician-supervised nutrition and exercise program. Also, GI and cardiology specialists have not recommended this procedure". After receiving this I called Healthease and they stated as of 12/31/05 I no longer had Healthease, that Medicaid had cancelled me. When I called Medicaid they informed me that my income must have changed and I no longer qualify for Medicaid. I informed them that there was nothing in my situation that had changed they then stated someone would get back with me - the next day I called back and said someone was to call back and I had not yet heard from anyone, they then decided to inform me once again that my situation must have changed and I would fall under medically needy and my children could keep Medicaid. I found this to be very fishy that this would happen once they found out I was trying to get approved for wls. Items sent to ins. 1. Pcp recommendation and clearance (all records for over 18 months) sleep apnea, high cholesterol and moderate aortic regurgitation (due to fen-phen). 2. Cardiologist clearance 3. Psychiatric clearance Plan guidelines 1. Morbid obesity 2. Documented trial of physician-supervised weight reduction for a minimum of 12 months. 3. Psychiatric evaluation 4. Recommendation for surgery by the specialist managing the patient's co-morbid conditions. 5. Multi-disciplinary approach by the surgical specialist pre post-operatively. 6. 18 years or older. I am going to try and get Medicaid straightened out but in the mean time need to work on my appeal letter----can anyone help with letter if you have some I could look at as reference material it would be well appreciated. Anyone with Healthease needs to know these things because if you call they will not tell you up front what their policy is.

try to get them to put you on stay well

Sounds like you have your hands full. I think you're taking the right steps, first re-instate your insurance and go to the insurance commision to complain and get some help, you can find them online and alot of other florida based information at www.myflorida.com. Good luck!

Thanks, I think I just needed to vent. Wish me luck

Hello, I went through the same problems. The link bellow is to the Milliman & Robertson guidelines for gastric bypass surgery. Your insurance does not want you to see this. They claim that you do not qualify, but if you read this guideline you will they are just stalling. They just hope you give up and do not appeal. I gathered as much info as I could and faxed it to my ins. after my 2nd appeal was denied. Let them know you will hire an attorney if they deny you. However, you must meet the requirements on that guideline. Most overwieght people do.