insurance appeal?

I posted this to the insurance board, but it looks like there haven't been too many responses over there in a week.  If anyone here has guidance, it would be appreciated. 

I have Compass Rose Health Plan (a federal employee plan).  My brochure states bariatric surgery is cover under the following conditions:

"Surgical treatment of morbid obesity (bariatric surgery) – a condition in which an individual (1) is the greater of 100 pounds or 100% over his/her normal weight (in accordance with our underwriting standards) with complicating conditions; (2) has been so for at least five years with documented unsuccessful attempts to reduce under a doctor-monitored diet and exercise program and (3) is age 18 or older."
 
I finally got through all the testing and such with the DR and my precertification was requested, and the insurance is asking for proof I did a 6 month supervised plan within the last year.  That's not what the brochure states.  Further, I called and spoke with multiple people (getting multiple interpretations of the policy and none of them would provide me with info in writing).  One of the answers I got that I agree with was that as long as I had a monitored plan (of any length) within the previous five years, I would be covered.  I submitted paperwork with a 3 month plan from 2008.

I give all this background because I have a feeling I am going to be denied.  I recently started to visit the Dr monthly while doing weigh****chers just in case, but I don't want to wait another 4 months.  The timing would be bad.  Is there any point to appealing the decision based on misleading information in the brochure and misinformation from the customer service reps?  I appreciate any insight.

I don't know anything about your particular insurance but I can speak of insurance approvals in general.

Do what they say.....exactly what they say.....and don't deviate.  They WANT you to give up so they won't have to pay.  It just amazes me that they'll pay for all the morbid obesity problems like diabetes and heart failure but the don't want to fix the problem.

First of all, make SURE you have the EXACT, up to date, contract that is provided by your employer.  That contract changes from year to year so be sure its the 2011 contract.

Next, if they want 6 months supervised, no problem.  Your surgeon is going to require you to see a psychologist and a dietician and probably a weight loss counselor.  You can see those people, one per month, and 3 months will be gone before you know it.  During those 3 months, be sure you weight in and its marked in your chart.  It will all count towards your 6 months.

And NEVER skip a month of miss an appointment.  The insurance company is in hopes you'll do that.  Then they make you start all over. Trust me.  I've seen it happen more than once.

Basically, you can go to your PCP for 3 months for any other appointment but just be sure to weigh in and have them note your file that they talked to you about the weight issue.  My doctor gave me meds to take (which I didn't) and thus when there was no weight loss, I showed the drugs didn't help.

My surgeon actually told me I could do the last 3 weigh ins at his office when I came to see his bariatric coordinator for my first appointment, the dietician for the second and the psychologist for the 3rd.  Then the paperwork went in with all the i's dottes and all the t's crossed and I was approved in 12 working days.

Bottom line here is you HAVE to do exactly as they say or they won't pay.  Be sure you have the current contat and go from there.

Good luck.  There are usually lots of hoops to jump thru but they hold the checkbook so you have to bow down to them.

LaWanda

I don't have your insurance type but had the same issue.I was denied after going through the whole process. My primary physician referred me to nutritionist. had to do 8 weeks of diet attempt. I could of also done wiegh****chers they said.long story short i finished and just got a pre authorization from insurance. don't quit.

I would also like to note this was a new rule implemented in January of 2011 in my case ,initially i didnt need the recent diet attempts but submitted my paperwork a few days after implemented.. so this may have been why you didnt notice before.

Just give them what they want.Its only 4 months and well worth it. I gave up the first time I applied and ended up with congestive heart failure to add to my co morbeditys. I wish I would have stuck with it the first time. They do jerk you through the wringer though. Hang in!