Appeal Letter & Self Pay Info

Ok Humana has denied me and after many phone calls I have found out why. They said it was a Contractual Issue and that it is not in my policy. I asked if that means it is excluded and they said that it means it is not included in my ploicy and that my policy says nothing about this surgery. They said they are not arguing that it is a medical neccessity just that it is not in my policy. I am still very confused. I figured that they would just use the word excluded but they kept saying that it is not included. I figure I will go ahead and send in an appeal letter anyway and see what happens. I need help with an appeal letter so if anyone has some samples I would greatly Appreciate it if you could send them to me. This is the second denial I have had to go through because last year BCBS denied me also. I am so very upset. I will also be looking into self pay so if anyone has any info on the cost I would appreciate that also. My doctor will cost $22,000.00 and I am not sure if that is a good price or not. I have three children and I kind of feel bad about spending that kind of money on myself but I would also like to be around for them later in life also. I am not trying to be to cheap and end up with a butcher doctor either. SO MY FAMILY I REALLY NEED SOME HELp, SUPPORT, ADVICE AND GUIDANCE HERE. Thank you so much in advance Sherri

We had to self-pay my surgeon because he was not a provider for our insurance. It was worth it to get the one that we felt was the best choice. His cash pre-pay price was $3500. They have arranged a negotiated rate for cash patients that includes the hospital, the anesthesiologist and the surgeons for about $14500, if I remember correctly. The surgeons are unsurpassed and the facility (St. Joeseph East in Lexington) was wonderful. You might want to check into this program, it sounds like it would be worthwhile. Dr. Steiner is the greatest! Rhonna

Thank you so much Rhonna. I will for sure check into your Doctor. So when you self pay do you have to have all the money up front? I know nothing about how any of this works. I think I will look him up in the phone book and call him right now. Thank you So much Sherri

Hi Sherri, You certainly can't go wrong by choosing my doctor. I have seen a LOT of doctors through the years and I am just totally impressed with him on so many different levels. It is due to his knowledge, expertise and attention to detail that I am here today! When we self-payed the surgeon, it was required before surgery to get the discount (I think his regular price was about $6500). When I went into surgery my husband went over to the office (connected to the hospital, so handy!) and paid the fee. I don't know if they would require the entire amount (hospital/anesth./surgeon) all at once. They will be able to tell you. They also have a superb support system. Because of the distance, I can't always get to all the meetings, but I really try because I know they are important! If you have any questions, please don't hesitate to ask. This is an important decision! Rhonna

I do thank you very much. This is a major decision and like I said I have children and feel kind of guilty about spending this kind of money. This has been my second denial through 2 different insurance companies. I found your doctors phone number and I will call him as soon as I leave work today. Did your husband pay for everything in advance like the hospital and anesth. I do have about $16,000 that I have access to so I will be calling him. My husband is not happy about spending so much money on something like this. We have been together for 18 years and I am only 32 so he has seen me lose and gain weight all these years. I have no problem loosing weight I just cant keep it off. He is not being very supportive or nice about this but I am doing it even if it means leaving him over it. I really want to be around for my children. Thanks again for the info and advice. Sherri

I am happy that you are checking into this program. I think you will be very impressed with everything about it from the doctors, to the staff, the support and the hospital. One thing that I really liked is that the hospital gives the bariatric patients the private rooms first so that the husband, SO or whoever can stay with the patient can be there 24/7. My room was large, cheery and had a sofa sleeper that my husband stayed quite comfortably in. The staff there is really great, one of the nurses (Kristi) had bariatric surgery with Dr. Steiner, as well. She was invaluable! The tech that helped with the gastroscopy in pre-op testing was also a patient of his. She was an inspiration! Our insurance covered a portion of the hospital and anesthesiologist, so that was submitted through insurance and we paid what was left. To get the surgeon that we wanted we had to pay up front, since he was not a provider for our insurance. We had other options, but we wanted Dr. Steiner and were willing to forgo the insurance coverage to get the surgeon we had chosen after much research. We have never regretted that decision, not for one moment. You sound SO much like me. I could lose weight pretty easily, but it was impossible to keep off and each time I regained more. I was approaching 50 years old and terrified that if I didn't stop the cycle I would be wheelchair bound since my feet were showing severe damage from the weight. My husband was afraid of me having the surgery at first. Then he started researching it and became more comfortable with it as his understanding of the procedure and it's benefits increased. The money was a HUGE issue for us and as it worked out, he ended up being out of work from right around my surgery date until just a few weeks ago (almost a full year). We had to take the money from our line of equity on our house to pay for the surgeon. But we sat down and talked about it... we decided that making this investment in my health and OUR future was way more important than remodeling the kitchen in our house. What good is a fancy house if your loved one is no longer there to share it with you? He was scared to death of losing me to the comorbidities of carrying all that extra weight. We'd waited a lifetime to find each other, we wanted every chance at a LONG future together! I hope that your husband comes around and becomes supportive of you. He has so much to gain from you having this surgery and becoming healthy again! But when all is said and done, this is YOUR body and only YOU can make this decision and do the work to make it successful. You need to do what is right for yourself and your children who depend on you. Let me know how things are going... maybe we will see each other at a support meeting someday. BTW, the first step to this process is attending one of their introduction seminars. If you know for sure this is what you want, they will have some appointments available that you can sign up for right at the meeting to get your journey started as soon as possible. That's what I did... I had my first appointment within a few days and my surgery was 32 days from the introduction seminar! I'm excited for you... it's a wild ride, but worth every moment of it! Rhonna