insurance denial

hi everyone....I am in need of some help.  I finally got the ok from my doctor to have bariatric surgery, she sent the insurance company a letter requesting I have the surgery.  I got a letter from the insurance company last week, it was denied    I  need to appeal the decision but really need some guidance on writing the letter...anyone know where I can go?...thanks

What is the reason they gave you for the denial?  Did you call your insurance company before the letter was sent to find out exactly what the requirements are to be approved?  Did you complete all the resting and meet all the criteria like BMI and comorbidities and diet history?  Have you seen a surgeon yet or only your PCP?

Hi Pam, The reason they gave for denial was that bariatric surgery is excluded from my coverage under the terms of my contract.  They also went on to say if I was dissatisfied with the decision I should begin a formal grievance process...sending a detailed letter explaining the situation, outlining why I feel the decision should be reversed and also enclose supporting documents.   I have been trying to have this done for 5 years now, my weight loss/gain is drastic, I lose a lot then gain a lot.  I contact Henry Ford Bariatric Surgery Center to find out how to go about looking into the program.  They told me to contact my doctor and have her write a letter to my insurance company.   My doctor wrote the letter and a few weeks later I got the denial letter.  So no, I never called the insurance company first.   I do know I want to start the appeal process....I honestly feel with the way I have been feeling lately that my weight is the number one reason I feel like I do. Thanks for taking the time out to respond. ~Debbie

Red Wing fan, Hang in there, OK?  We're all routing for you! Getting an OK from the doc is only part of the process.  Usually (depending on the insurance policies) you'll need to have 6-12 months of documented attempts at losing weight (Weigh****chers and LA Weight Loss come to mind) an EKG, blood work-up, a visit to a friendly psychologist, etc.   Did the insurance letter give you a reason for the denial? If you have already met their criteria, then it is a matter of standing firm and appealing the denial.  Let us know of progress and how it goes for you, OK? 

Mike, Thank you for your response, I truly appreciate it.  I do have documented attempts of weight loss, EKG, blood work but not a visit from the psychologist yet.  It seems like all my life I have been trying to lose weight, but more recently at Medical Weight Loss and Weight ****chers.  I lose a drastic amount of weight and then it comes back plus more.  A few months ago, at one of my doctor visits, my doctor suggested Bariatric surgery....she sent the letter of request to the insurance company and a few weeks later I got the denail letter.  After speaking to a few people who have had the surgery and from support here, I understand that the ok from the doctor is just a small part of the process.  I am usually a very quiet person but I guess I'm going to have to really stand firm with the insurance company and appeal the denial strongly.  I will definately let you know of the progress .   Thank you again for your response, Debbie

Sorry to break this news to you, but if your plan specifically excludes bariatric surgery, there is not a whole lot you can do.   It's not like you do not meet the critera - they just do not cover it.  I would still do the appeal process, sometimes - depending on the cir****tances, they do make exceptions.   Do you have other insurance options?  Does your company offer more than one company you can choose from.  Do you have a spouse - does his cover it.