Appeal Letter

I was told in the beginning when I took my first seminar that lap band would be covered. After I go through to the process of getting my paperwork together and attending appointments after appointments, my packet was finally complete and ready to turn in. Yet, once the carrier received the packet, they denied my claim stating the procedure was not covered. Go figure!

Does anybody have any type of appeal letter they can share with me?

Thanks in advance.

Here is an Example I found here!!

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,

 

Hi Your insurance may not cover the lap band, but may cover the rny gastric bypass.  More insurance companies will approve the gastric bypass vs. the lap band.  Worth checking into with your insurance company.

May God travel with you on this journey.

My insurance would not cover the lap but would cover the RNY. Call the insurance company and find out what their coverage is on WLS. Then put in for that specific one. Hope this helps. Barb MyNiceSpace.com