Denied

I am just in tears now and so mad. Well I got my denial letter today. It said, "According to the documentation provided, you do not meet the clinical criteria for surgical treatment of morbid obesity. You do not have a BMI of greater than 35 in conjunction with severe co-morbidities such as cardiopulmonary complications or severe diabetes. You have not met the weight reduction requirement as evidenced by a weight loss of 8% prorated for you per the letter sent to you in May, 2005." Yes I know I didn't meet the required 8% loss from my starting weight but I lost 10% of my highest weight. The new criteria did not go into effect until after I had gained weight. I also I talked to Mary Goble from CHP back when I received the letter and they said that if I lost down lower than 35 BMI that it would be no problem. As long as my starting BMI was 40. I am so ticked off right now. I am going to file an appeal letter and send it in Wed. after I have weighed in a proved that I have gotten off the required weight. I only had 6 lbs to lose. Does anyone have any samples of appeal letter to the insurance companies?

Angie, I'm so sorry to hear you got a denial letter. Definitely appeal! I used to have an appeal letter saved in case I needed one which I didn't. I'll look to see if I have it still. Jan has a general letter she wrote and sent in to her insurance company on her profile which she feels helped her get approval, check that out. I am a bit confused though, you had to LOSE weight to qualify for your surgery???? maybe I misread that. Amy

Yes my insurance company came up with a new requirement when I was already a few months into the year long program. The requirement was that you must lose 10% of your starting weight. Well they prorated my weight to an 8% loss since I was already in the program. But I had put on weight by then so I had to lose the 8% plus the extra I had put on since the start of the program.

Found the website info I had saved. Just add (http://) minus the parens to this: mygastricbypass.com/appeals.htm Good luck!

Dont give up! Keep your chin up and fight this as much as you can. It could turn out that it was jsut not the right time for you. My best wishes to you. Heather

I am so sorry for your denial Angie - but don't give up!!! Fight, appeal, fight, appeal, fight - do whatever it takes to win this - you deserve it! I took 2 years to get approved by Cigna, I gave up at one point but then started right back at it - did the 6 month diet and resubmitted. I thank God every day that I didn't give up. You'll win this - just keep focused and have faith!!! Much love, Carol