Declined my appeal letter

Had surgeon consult on June 6, 2006. Sagamore Plus Insurance has declined coverage. Just got the 2nd decline letter. I had a wonderful letter from my PCP. A fantastic letter from the surgeon. The reason for decline is simply that I do not have 18 months of consecutive doctor visits for the sole purpose of weight reduction supervised by the physician. The insurance company said that some of the doctor visits also included other medical reasons for the visit!!!!! The PCP has seen me for 24 months and everytime my weight was discussed and weight reduction methods were suggested. I've even gone to the local fitness center for 18 months in an attempt to do this the "other" way. I've dieted since my teenage years. That makes about 40 years of every diet you can think of. I'm soooooo frustrated!!!!! Is there any hope! Anyone have any ideas how to get approval? I jumped through all the hoops put out by the insurance company and still have a "NO"!!!! This response only feeds my feelings of failure and hopelessness and depression. Thanks for letting me vent!!!!! Good luck to you all! Stay well!

Vicki, Trust me, I do know exactly how you feel. Contact Sagamore and ask them to send you specific guidelines for how/when your psp visits should be. Also, find out when their contract expires to where they will HAVE TO abide by the Indiana stat law of not requiring any more than 6 months of supervised dieting. Don't give up. It is so worth it! Sherri

Thanks Sherri for your comments. What do you mean by "when their contract expires to where they will have to abide by Indiana state law". I found the info on the 6 months instead of 18 months; but don't understand how that works. Do you know where else I can get more info on that or what it actually means to me? I just feel lost right now. Don't know what to do next. But that was a good idea about the specific guidelines. I will definitely do that. Thanks, Vicki

Vivki, This is a quote from an earlier post by Aunt Johnnie: "It goes on to say that the new law was recently 'clarified' and that even though the law goes into effect on July 1, it doesn't affect insurance coverage until the plans are renewed with the employers. Mine is renewed in January." Hope this helps... Sherri

Vicki, I was reviewing old letters regarding insurance denials and came across yours. I was also denied the other day by Unicare and am in the process of writing up a letter to them for reconsideration. I also got denied for the same reason.....needing 18 months of physician monitored diet. I pretty much did what you did. I will be asking them for what they want exactly...in writing. I figure I can try and I'll be no less than where I am now if they deny me again. My company renews insurance in Feb or March so I figure that is about the six months (a bit more) that the law requires. My question is.....have you done anything else since you were declined? Have you talked to them more, have you seen the doc for exactly diet purposes? My doc referred me to a dietician, whom I saw today, so that we have all bases covered. Please let me know if you've done more. Thanks! Anna

Anna, After the 2nd decline from Sagamore, I went back to my pcp. She is seeing me every month to satisfy the insurance requirements. She writes in her notes "this visit is for the sole purpose of obesity". We then discuss diet and a plan. One of the problems with my medical records according to Sagamore was that I saw the dr. for other reasons. Weight was not the primary reason for the visit. Our insurance is renewing in November. I work for a very small employer. My concern now is that the insurance company will choose not to offer a renewal or jack the premiums up beyond reason. Knowing that I am an employee and that I am pursuing WLS may cause a BIG problem for my employer and co-workers when the renewal is issued. Good luck to you! Vicki