Now what??!

Dear Dr. Berkowitz, We have received your request for pre-authorization of benefits for Roux-en-Y gastrojejunostomy. Based on the information we received, we are unable to pre-authorize this procedure at this time. According to the Advanced Data Comm Health Plan document, charges for services or supplies furnished for weight reduction or in connection with morbid obesity; except as specifically shown as a covered exspense elsewhere in the plan. Office visits and related laboratory tests for the treatment of morbid obesity will be considered Elligible Expenses. One course of treatment as documented by a physicial will be covered. At the end of the treatment plan or if the individual discontinues treatment, coverage will cease. This includes dietary supplements, foods, equipment, laboratory testing, exams and prescription drugs, regardless of whether or not weight reduction is medically appropriate. This pre-authorization denial in no way implies that the service is not medically appropriate or beneficial to the patient. However, Self Insured Services Company is the third party claims payor for the Advanced Data Comm Health Plan which is subject to ERISA. All claims must be processed according to the Plan Document guidelines. Sincerely, SISCO Claims Department ... They denied me! I don't understand what any of this means... Should I appeal? I can't tell if my coverage does or does not cover the surgery 'regardless of medical necessity'. I don't even know where to begin, what to do to appeal. Help! Please? I'm so confused right now...

Hi Jacqueline! Do you work in the Oelwein office by chance? If so, good luck! I worked there for a while and their insurance is pretty much a joke. You would probably be better off finding another job with good insurance. Good luck and best wishes! Blessed Be! Sherry

When my husband and I tried for approval for invitro 8 yrs ago, our initial response was denial based on that the ins company did not cover anything to do with infertility. We got all discouraged and just about gave up but decided to call the ins co again anyway. Turns out it was the parent company of our regular health ins that denied, the subcontracted companies still had jurisdiction whether to approve or not. That was a generic response to our request. We now have a daughter to show for our efforts!I don't know if this applies in your case but its one more stone to overturn. Getting a different job in not always an option in a small town but something to consider. Generally something in the medical field has pretty good reasonably priced insurance. Some computer skills could get you into PDC hospital or any of the surrounding clinics as a receptionist\registration specialist. Don't give up!