Has anyone been denied after 2nd appeal??Help??? :help:

Hi my name is Dina I am from Levittown NY I had all of my pre-testing done and was ready for surgery, then My Dr. submitted and I was denied.. He appealed and I was denied again. I am afraid for him to submit again... what if they keep denying?? The reason was that they were unhappy with the Psych. It wan't professional enough... So I went to a differen psych. and all is good... I am so nervous that they will deny it again... Any Support out there??? Thanks so much Dina

awww dina i am so sorry i will say a prayer for you hun. be strong!!!! julie k

Thanks for the support Julie!!! It Helps ease the stress. Dina

Hi Dina! Don't get discouraged. Insurance companies have specific approval criteria, and once they get what they want they can be reasonable! Please don't be afraid to appeal on your own if needed. Just because your doctor(s) appeal, doesn't mean that you can't, too. Usually the insurance companies call that a complaint or a grievance (grievances usually are about things the company has already made a negative determination about). Call your insurance company and ask them to send you their specific criteria for bariatric surgery approval, and ask them to be as specific as possible in giving you the details of what they need for approval. You can ask for this information even if you don't file a grievance right now. Even if your doctor or member appeal(s) continue to be denied, you can contact the NYS Dept of Health and file an external appeal (your insurance company can provide you with an application for an external appeal if you request one) at any point - even while an insurance company appeal is in progress. The phone number for the NYS Dept of Health is 1-800-206-8125 (Monday - Friday 8:30 am to 5:30 pm). I would suggest, though, that you take it to the State after all appeals to your insurance company have been made, unless your doctors feel that you are being denied totally unfairly. As for the psych eval, the insurance company is trying to make sure that you are handling things well. That, even if you suffer from depression, you are not in an active - uncontrolled - depression. They want to be assured that you understand that WLS is not a cure and that you are willing to make changes in your behavior (especially eating behavior) to ensure you will not only lose the weight but do not undermine the surgery by eating over your emotions (thus stretching your new pouch). Of course, they know that these psych evals are not fool-proof, but they are just trying to do whatever they can to ensure success. I doubt your doctors would do something as stupid as one I know of did - telling the insurance company that the patient was actually trying to gain weight to ensure a higher BMI! Dumb, huh?! Good luck! BTW - I live not far from you... in Massapequa! Have you attended any support group meetings? Feel free to email me if you'd like, any time! ~~ Ilene Rachel 6 months post-op 100+ lbs down!

Hi Ilene Thank you for the words of encouragment and advice!! I have recieved info on an external appeal... but I am hoping that the new psych. Eval will be what they want.. and I won't have to appeal the decision externally. I am also writing my own letter of appeal to them along with my pcp & endocrinologist's.. I do go to my surgeons support group in Mineola once a month.. Dr. Vithiananthan. Thank you for your kindness!! and we are neighbors! I am right off of 107 in Island Trees!!

my only advice to you is to never ever ever ever ever give up never ever Stacy 232/150/140