Getting Authorization - Insurance trouble

Welcome to insurance the insurance nightmare! That's the name that thousands of people have more or less independently come up with to describe their experiences with working with their health plan.

If your request for coverage has been denied, then the next step is to send in an appeal letter. It is good to have one of these already on hand ready to be signed by your doctor/surgeon and sent in. Some insurers have been known to systematically deny all applications, only acting upon appeal letters or second appeal letters.

The appeal process

The majority of the insurance companies will include instructions to appeal their decision. Some will include the paperwork to use for the appeal and some will suggest a telephone appeal. The telephone appeal isn't recommended at all because you can more effectively present your data in a written form. You can fill out their paperwork, but be sure to include an appeal letter also. You should include your previous request for preapproval and all the paperwork that went with it. It is well worth it to ask your PCP to write another, more forceful letter.

What to do when you finally get an answer and it's a rejection

1. Be persistent. “No" does not always mean “no, never"; it can mean “no, not right now"! You always have the chance to request and request and request. Often times after a second or third request that's been denied it automatically goes higher. Hang in there.
2. Speak to your doctor. Your doctor and/or his office staff should be willing and able to telephone and follow up with a written letter to your insurance company to substantiate medical grounds for a reversal of the insurance company's denial of your original request.
3. Appeal the decision to another level within the company. The appeals process may lead you to the very people responsible for setting policy about reimbursement for weight-loss treatments. Each health insurance plan may have several different levels of appeal. This can be a time-consuming process, but don't give up.
4. Contact your state's insurance commission in writing to describe your needs and difficulties. Send copies or summaries of your communications with the insurance company. Then, be sure to let your insurance company know that you've contacted the commission on your own behalf.
5. Write to state and federally elected officials who may be able to assist you in the appeals process. Update them on your situation and enlist their support on this important issue. Don't forget about the Attorney General's Office; the AG can be VERY persuasive!
6. Contact the Office for Civil Rights in your location. The OCR investigates written complaints of discrimination of the disabled under the Americans with Disabilities Act, in housing, public accommodations, the workplace and education. Morbid Obesity has been defined by the ADA as a qualified disability under the context of the law. Let your insurer know that you have filed this civil rights complaint — this may be just what gets good results.

Sample Appeal Letter

Dear Sir or Madam,

This letter is to appeal your denial for RNY gastric bypass surgery (Diagnosis Code 278.01 Procedure Code 43847).

I was referred for this surgery by my PCP, who is very concerned about my health because of severe morbid obesity. I am a ___ year old morbidly obese male who is ______ tall and weigh ______ lbs., giving me a body mass index of ________. The body mass index is calculated by dividing a person's weight in kilograms by their height in meters squared. When a man's BMI is over 27.8, or woman's exceeds 27.3, that person is considered obese. The degree of obesity associated with a particular BMI ranges from mild obesity at a BMI near 27, moderate obesity at a BMI between 27–30, severe obesity at 30–35, to very severe obesity for patients with a BMI of 40 or greater^1,2,3. Therefore, I may be classified as being very severely obese. The annual number of deaths in America attributable to obesity has been estimated to be 300,000 deaths per year^4,5. With my abnormally high BMI, I am at an estimated 190 percent increased risk of death at my present weight.

I am having significant adverse symptoms from my obesity. I have difficulty standing. I have difficulty performing my daily activities, and in participating with my family in recreational activities. I have arthritis and pain of my weight-bearing joints. An increase in body weight adds trauma to weight bearing joints and excess body weight is a major predictor of osteoarthritis of the knees. This is a mechanical problem and not a metabolic one. Weight loss will markedly decrease the chance of developing osteoarthritis.

I also suffer from shortness of breath. There are several abnormalities in pulmonary function in obese individuals. At one extreme are patients with so-called Pickwickian syndrome, or the obesity-hypoventilation syndrome, which is characterized by somnolence and hypoventilation; it eventually leads to cor pulmonale. In patients who are less obese, there is a fairly uniform decrease in expiratory reserve volume and a tendency to reduction in all lung volumes. A low maximum rate of voluntary ventilation and venous admixture is also present. As an individual becomes more obese, the muscular work required for ventilation increases. In addition, respiratory muscles may not function normally in obese individuals.

Because of my acid reflux and pains and aches in my back and legs I have difficulty sleeping, and therefore, am fatigued and tired during the day. This surgery usually cures acid reflux and sleep disturbances.

I have borderline hypertension at this point. Hypertension is a common concomitant of obesity.

I now have bone spurs on both my feet that are aggravated by my weight.

I have made many, many attempts to lose weight and this has gone on all my life. I was put on medications by my doctor to help lose weight. I have been put on medications over and over again. I would lose some weight then gain it all back, and more. I have also tried many exercise programs. I have tried Nutri-System. My primary care physician put me on Redux. As you can see, I have spent all my adult life trying to lose weight. I am now at the very edge of complete disability and am at a point where everything is an effort. The obese individual has functional impairment in the activities of daily living. This dysfunction impacts sleep, recreation, work and social interactions.

 

Economic costs of Obesity:
Obesity has been shown to directly increase health care costs. In an article in the March 9, 1998 issue of the Archives of Internal Medicine 17, 118 members of the Kaiser Permenente Medical Care Program were studied to determine the association between body fatness and health care costs. The results showed that patients with BMIs greater than 30 had a 2.4 times greater risk for increased inpatient and outpatient costs than patients with BMIs under 30.

Indirect costs:
Americans spend an additional $33 billion dollars annually on weight-reduction products and services, including diet foods, products, and programs. Most of these expenditures, as is evidenced in this case, are not effective. Rather it can expected that they will continue to gain weight and the costs of co-morbid conditions, including the ones they already have and ones they surely will acquire as time goes on, will far outweigh the costs of gastric bypass surgery that we are asking you to please approve for me.

As you can see I have exhausted all the traditional ways to lose weight. The gastric bypass is an approved and proven means to permanently lose weight. Please approve this surgery for me. Thank you.

Sincerely,

 

Reference sources:

1. Weighing the Options: Criteria for Evaluating Weight-Management Programs. Institute of Medicine, National Academy of Sciences. 1995; 50-51.
2. Kuczmarski, R.J., Johnson, C.L., Flegal, K.M., Campbell, S.M. Increasing prevalence of overweight among US adults. Journal of the American Medical Associatio*****; 272:205-211.
3. Troiano, R.P., Kuczmarski, R.J., Johnson, C.L., Flegal, K.M., Campbell, S.M. Overweight prevalence and trends for children and adolescents: The National Health and Nutrition Examination Surveys, 1963 to 1991. Archives of Pediatrics and Adolescent Medicine, 1995; 149:1085-1091.
4. Daily dietary fat and total food-energy intakes: Third National Health and Nutrition Examination Survey, Phase I, 1988-1991. MMWR Morbidity and Mortality Weekly Report. 1994; 43:116-117, 123-125.
5. Weight control: What works and why. Medical Essay. Mayo Foundation for Medical Education and Research, 1994.