I need advice on appeal situation

I got my denial letter in the mail today. I have up to 2 years to appeal a decision. We already know Im going to appeal. This where I need advice. I can either have my new PCP appeal on my behalf either in writing or by requesting a peer-to-peer review and submitting supporting documentation (I was denied for diet requirement), or I could appeal on my own also with supporting documentation, and I have already requested another set of my medical records to be sent directly to me from former PCP for this reason. I have two questions. Would you let PCP appeal on your behalf, or would you appeal for yourself. Plus, if I send my own appeal letter can I also switch PCPs again? Im thinking I may have been to hasty in chosing a doctor downtown as it is not conveinent for me at all. Is it risky to change PCPs during an appeal process? Will I have to start all over? (Im thinking not since the referral was already requested and denied).

Didn't HAP change their requirements as of 1-1-06? I thought you had to do their 12 month program. Did it say anything like that in the letter. I would find that out first before I appeal. Also, did they tell you what you were lacking?

it says I was denied based on lack of 12 months medically supervised diet documentation. It also states that they only accept a multidisciplinary program, pretty much "their" program, but it doesn't state that it has to be through HAP/HF. But the program does have to have a bariatric doctor, exercise specialist, nutritionist, psych etc.

I am not really versed on the appeal process, just curious. I know HAP is very difficult, and does not ever want to pay for WLS. It was not that long ago that the only way to get them to approve it was through taking legal action with an attorney. I read many stories of people who had to do that. HAP is in business to keep costs low. They cannot do that by paying for WLS. They have always been a nighmare for us WLS potentials. I had them for years prior to my surgery and never bothered to try. I eventually was able to get BCBS. Don't give up, but be careful wasting precious time on an appeal if they will only deny you based on lacking requirements. I have worked in the insurance business and know that requirements for certain treatments are not negotiable. I would post on the main board to get lots of possible info as well. Maybe you can hook up with a HAP guru. Good luck!

I called them and asked them if appealing is even worth it at this point. She said yes, if doctor can show documentation that I was followed, then I can still appeal it. Here is the kicker, you also need a referral to the WOW program. If approved, HAP will cover the cost ($300 every 4 months). So my options at this point are 1) allow current PCP to appeal on my behalf and also request referral to WOW or 2) Appeal on my own behalf (still have to show documentation of attempts), switch PCP and have new PCP request referral to WOW. Per HAP, switching PCPs doesn't change the process, the new PCP would just have to pick up where the old PCP left off. So, now I have to decide whether it is smarter for me to switch to a local PCP and submit my own appeal after I get the copies of my medical records, or stay put and suffer the inconvience. Im kicking myself cuz I just didn't think it would be that much of a hassle, but now I realize its going to be if I have to go downtown each and every visit, not to mention if I get sick.

This just is so upsetting to me. I do not understand how a 12 month diet program for this situation is a "requirement"... the requirements should be necessity based..the co-morbidies and such.. and obviously documentation of previous attmepts... I just don't get this. Your insurance company is supposed to be there for YOUR benefit..for YOUR health..and this just causes more stress and anxiety and depression. I am a Christian, so I would never take my life, but I can honestly see how someone without strong convictions that suffers from obesity could see that as the only way out ..especially when it seems nobody will help you. I'm sorry.. I know that sounded harsh..but I feel it's true. Making someone who has dieted their way up to obesity their entire life should not HAVE to go on a diet again for another year before getting help. Then..are they promising an approval after you do that? I'm just venting.. sorry. Colleen, you know I am on your side and right behind you with this whole thing. Hang in there. I'll try to be more constructive once I get over being angry!!!!!

No apology necessary Kim, I feel the same way. Do they honestly think that Ive done nothing to get this weight off on my own? I get down some, the least Ive weighed in the last 20 years is 210, the most 284, Im at 277 right now, and I always gain it back. I need more help than a diet alone can give me. That is why I want the surgery. Im tired of being tired. Im tired of taking bp meds. Im tired of joint pain, back pain, headaches, heavy periods, infertility (this one is inconsequential now as Im done having children, but still), etc...

You are very right. I am extremely thankful for this surgery and encourage everyone to fight the fight of their lives. I am not a christian, and that was an option for me for a long time. If I had not had the surgery, I could not say where I would have ended up. Your anger is justified. We are wrong though to assume insurance companies give a crap about anything but the bottom line. That is all it is about. It is not about right or wrong with them. It is about money and the fiscal year. Companies do not worry about costs 10 years from now. What matters is what is on paper at the moment. You have to fight though. What other choice is there?

Colleen, what insurance do you have? I have aetna ppo and I was denied 2 times and on the third I ended up with a wonderful lady at the insurance company she told me not to give up because that was what they wanted me to do so I went and got all of my aers from the beginning again every docto, every diet made copies of everything wrote my own letter to them and basically told them if I did not have this surgery I did ot know how much more my body could handle and I also got letters from all of my doctors even my obgyn and I finally got approved 2 mths after I sent all that in I had my wls and it was the best thing i ever did.. God Bless You and good luck Tina

I have HAP HMO. Im going to jump through the hoops, I don't really have a choice, but I am still going to appeal while I jump. Im not gonna waste months and not be doing what they want me to do, KWIM? So, I will send the appeal with all the supporting documentation I can get my hands on and I will enroll in their stupid weight loss program until I either get approved or I have to appeal to the state. Its that simple I guess.