Please help! appeal advise

I have just been denied by Pacificare. They say it is not medically necessary for me to have the surgery. I have a BMI of 50. I am a diabetic, high blood pressure, and have joint pains. Where did I go wrong? I followed all of the rules, jumped through the hoops, what else can I do? My insurance will change at the end of the year, so if I don't get an approval now I am out of luck. Please say a prayer for me. If I am what they think is the picture of health I would hate to see unhealthy. Needs a prayer! Aretta

You may have to hire an attorney.

I fought for two years and appealed to the very end and finally a phone conference to get my approval (cigna HMO). You are absolutely right; what are they thinking? what the heck is unhealthy? sheesh! since your insurance is gone at the end of the year though; im not sure how effective an appeal would be. Will you be getting new insurance? Im sorry im not much help because of the loss of insurance thing...if you were staying with the insurance, I would say be the biggest pain in the rear to them that you can be!! call constantly, take down names and times and dates that you talk to ANYONE about ANYTHING insurance related and just use up every appeal available to you!! good luck!!!!

Aretta, you need to find out exactly what criteria you didn't meet for approval. With your BMI you shouldn't even need the co-morbidities. Make sure that they received all of your information and find out if any additional info is needed. Keep a positive mindset and do everything you can to get it into them as soon as possible. One other thought, and I hope I am wrong, is that since Pacificare is pulling out at the end of the year they are stopping or stalling the approval process so they aren't out the expense. Dennis

are you a state employee?? i am and i got approved, but it is getting close to the wire on what they will and will not approve. Are you going through Dr Floyd or Dr Pearce? Kenny walked me through it and i had a friend who had it 6 months before help me with a letter. I would be glad to send it to you to show you what i wrote. I had a doctor that sent a awesome letter just documenting how long he has known me and what i have tried in the past and that my weight was something we had been discussing for a long long time. Kenny seemed to think they lay alot on your letter and doctors letter almost more than the 2-3 years of medical records. i will be glad to help and am at [email protected] if you would like to email me! I will ship you a copy of that letter!