Suggestion for Appeal Please

Happy New Year Everyone!

After searching my soul, talking with my doctor and my family I decided to persue  the RNY surgery option instead of appealling the VS request.  I have been keeping my fingers crossed and well, it didn't help one bit!

I received a letter in the mail from UHC (insurance) last night which gives a vague denial of the surgery AGAIN.  I am so frustrated!!!!!!!!!!  They basically spell out the criteria and frankly, I am confused as to why they denied it.  I fit EVERY specification!!!  The hospital is in network and because the doctor was out of network, his office requested that he be considered in network and was given the okay.

What do I have to show them at this point to proceed?  Do I have to give them my first born or something?  Okay, that was a bit harsh, but gosh, I know of two other people that I work with that have had bariatric surgery with this particular insurance company.  I AM ABOUT TO COME COMPLETELY UNDONE!!!!!

If anyone has ANY insite, please don't hesitate to post!  I have a friend who told me that they would probably deny it the first go round, but just keep fighting.  I don't know what else I can give them to make the difference.  Please share...

Thanks!

Is this your first denial?  If so, yes appeal....get documentation of everything and submit.  Get as many physicians to write letters on your behalf.  I had several that did this for me.  Write your own personal letter explaining why you feel this is important.  Get as much documentation as possible on your co-morbidities.  It takes work but is so worth it.  I fought an exclusion and won on my first appeal.

I noticed on your profile that a co-worker had the same procedure done and insurance covered it.  Did she use the same surgeon?  If so the insurance coordinator should be able to help with this.  I was very fortunate to have a surgeon and other physicians to work with me.

Go on UHC website and pull up all your co-morbidities and see if anything says weightloss will help with this.  I did this with GERD, the website my insurance used said the only cure was medication and or surgery.  They never listed what type of surgery so I focused on this and fought my appeal this way. Copy and paste whatever you find from there website directly in your appeal letter.   I had 5 yrs of documetation of taking everything possible for GERD with no results, actually I was prescriped double the normal dosage on many with no relief.  My only other option was surgery....my WL surgeon, gastro and PCP said the typical surgery for GERD would only be temporary if I didn't get my weight under control....Yes, they all fought for me...I had my surgery three years ago and have taken nothing for GERD...I have no problems what so ever.

Also in my letter I got a lot of the cost for what the insurance had paid for my co-morbidities and also the contracted rate for the hospital and showed how they would actually save money by paying for the surgery.  I wrote that I knew that the insurance company was concerned about saving as much as possible and by not covering this procedure they were actually paying much more that they could save.  I know the insurance company is really in the business to make money, hit them where it counts. 

If you really want this you will have to fight...Girl fight for your life....good luck


Edit to add...

I had the RNY and have been very pleased.  I have had -0- complications and have done wonderful with it.  If you can't get the sleeve the RNY is not bad....I could never have done the band as I could somehow justify eating around it , can't do it with the RNY but again it has been great for me and I would chose nothing else.

Yes, this was my first denial for the RNY.  The vertical sleeve was denied because they still consider it an experimental surgery. 

I have UHC EPO.  I have a co-worker who also has UHC EPO and they covered the sleeve on the first go round...no appeal or review.  She used the same surgery center (different doctor, but same surgery coordinator)   Her sister, who also works with us has the UHC PPO and went through a different surgical center and different doctor had the RNY.  I believe she had to appeal it.

Co-morbidities?  Do you mean the complications incurred because of my weight like sleep apnea and insulin resistance and high cholesterol?  I just went to UHC's website and pulled up their "myuhc.com", the health and wellness section, which allows you to look up information on the different types of health problems and a section that shows estimated yearly costs of a type of illness.  I printed out everything I could find on the problems that I have and what do you know, high cholesterol can usually be controlled by weight loss.  I also looked up obesity and ti listed bariatric surgery as "the only proven way to achieve long-term weight control for the severly obese.  Hmmm, they would be paying approximately $2400 a year to maintain the health of my current conditions, not counting mental problems stemming from obesity.  My maternal great-grandmother lived to be 86 and my paternal grandmother lived to be 89 and my maternal grandmother is 81 and still kicking.  My mom is 61 and in pretty good health too.  So you figure, I am 42 this month, and say I live to be 65....that is 23 more years at $2400 dollars a year minimum.  Thats comes to over $55000 for my lifetime, not including any other complications that may result from my weight.  Wow!  Now you have me thinking....

I do really want this.  If I had the money, I would self pay.  I am so past the point of no return.  And I know that my husband supports my decision to do this too.  I just want to come out of this fat shell and live the best life I can live.

You know...I cried quite a bit last night.  I am mad as hell too.  What a way to spend New Years Eve.  I want this year to be a year of change for me and my family in so many ways.  I guess I have to buckle down and take what I want.

Thanks for lighting a fire under me and helping me with my new direction.

Kim

 

Ok, there you go...you are mad as hell.  That is the fire you need.  I too was mad. 

Get started on your letter of appeal and really think hard and long copy and paste whatever you can from the website.  Use it to your advantage.  I think I saw you were using an in net work hospital.  Call the hospital and find out how much their contracted rate is with your insurance company.  Mine was $1750.00 per day.  So basically my insurance only paid $1750.00 x the # of days I was in the hospital and the hospital wrote off the rest.  They basically paid $5250.00 for my WLS.  They were paying alot more than that in co-pays and everything else that I was dealing with.  Yes, I was seeing a counselor too, I included that cost and the fact that I was told I needed to have bladder surgery because my weight played a big part on my urinary leakage.  I used everything I could think of.  As far as the contracted rate a lot of people don't understand this.  If and insurance company has an agreement with a hospital or physician they set up certain amounts that they will pay and the hospital agrees to write off the difference and not bill the patient.  That is why it is so important to use and in network hospital.

In my letter I didn't say anything about wanting to lose weight for vanity issues.  I said I was very happy with who I was and the only problem I had with my weight was my health issues.  See if you can get any other doctors to write letters for you. 

Once you get all this together and hopefully your surgeons office will help you with a letter for their appeal call the insurance company daily and be sickening sweet.  Try to get past the regular customer service reps and talk with someone in the appeal division.  I got lucky and found someone to give me the direct # and I called everyday and was as sweet as I could be and then some.  I asked about their day and tried to get personal with them.  I think this too helped. 

Again, I had an exclusion with my insurance but I think by copying and pasting directly from their website and adding  the money issues it made them realize I was dead serious.

Good luck and if you need anything send me a private message.  I don't come on the LA board very much, just a stroke of luck that I came on today.  I honestly can't remember the last time I even lurked on this board.  I do frequent other boards all the time so I am on OH on a daily basis.