Denied Again...Where Do I Go From Here?

ganurse
on 9/14/04 11:36 am - Columbus, GA
I've once again been denied after re-appeal from First Health through HCA Healthcare. You'd think that a policy that just recently instituted a provision specific for weight-loss surgery AND added a unit to the hospital specifically for weight-loss surgery would approve their OWN EMPLOYEES!!! I'm just so depressed, frustrated, and angry all at once. Fluctuating between crying and throwing things....aughhhhh Got a copy of the actual policy and their only criteria is that it is "medically necessary" however they are denying stating that I don't have enough documented attempts with my PCP of specific weight loss. BUT...I've been followed for the last 2 years for my diabetes whi*****luded diet, nutrition classes, and weight loss. I even had a great letter from my PCP with my reappeal stating that he thought this was my last option for long-term success. Don't know where to go from here. Dr's office is suggesting to pow-wow and bringing in the insurance commissioner on this one and going to the hospital administrators (since our health policy is specifically for our corporation). Does anyone have any other suggestions?
Siddy I.
on 9/15/04 2:01 am - Savage, MN
First off: DONT GIVE UP!!! Thats what they want you to do. Instead start the next level appeal (your surgeons office SHOULD do this for you) and FIGHT FIGHT FIGHT!! And if you contact the insurance commissions office that will let them know that you aint playing their game. They will open an investigation as to what is going on and if your insuracne company can not come up with a good excuse for their actions, they know they can get into serious trouble. Just make sure your ducks are in a row. What does your insurance say about WLS? You have to get down to the nitty gritty as to what they require. If you need more info e-mail me and I'll be glad to help. Third times the charm here! Sid
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