Need advice on denial

djmissa
on 12/17/06 8:23 am - North Versailles, PA
 I was wondering if anyone can give me some advise. I just spoke with my surgeons office on Friday and they informed me that I was denied. I was devistated!! I just cried all day. They gave me the name and number of the doctor that handled my insurance claim and told me that my PCP would need to contact him. They told me that I could appeal but didn't go into any details and basically said to wait for the letter to come in the mail. The reason was because they went with my BMI when I started which was around 38. Currently, I am at around 41. I gave up smoking in July when I started my 6 month diet and of course, gained weight. Everyone there said it would be fine as long as I maintained my weight. That was the point of the 6 month diet. Well, after gaining some weight I had 2 weigh-ins where I did lose or maintain the weight. My nutritionist told me that I should be fine also. It was like someone punched me in the face. I am going to appeal but need some advise on how to do it. I do not have any co-morbids. I was happy that I didn't have anything wrong with me. Why should I wait to develop diabetes, heart disease or something else before I decide to go through with this? I went into this looking for a tool not a cure. I understood the risks. I do have a family history of obesity, diabetes, thyroid and heart disease. My mother did not agree with me about the surgery but she said she would be there for me. She is around 320lbs and I just feel like I am heading in that direction. I am trying to keep positive and I do not want to turn to food because it will just be worse. I have UPMC health plan. I guess one of my questions would be, how long will I have to wait to try again? Any help would be greatly appreciated. Thanks
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(deactivated member)
on 12/17/06 10:36 am
gary viscio
on 12/28/06 7:48 am - Oceanside, NY
RNY on 07/01/03 with
They gave me the name and number of the doctor that handled my insurance claim and told me that my PCP would need to contact him. They told me that I could appeal but didn't go into any details and basically said to wait for the letter to come in the mail.  Make sure you get the written denial because they'll sit on it so as not to start you appeal clock ticking.    PA has a great external review process, so you should appeal while you are getting your ducks in order, i/e making sure you meet the requirements under the plan.
Gary Viscio
www.ObesityLawyers.Com
RNY 7/1/03  -166lbs
djmissa
on 1/1/07 12:22 pm - North Versailles, PA

Well, I did receive the letter and decided to call the number they gave me.  They told me that I could appeal in writing or over the phone.  I decided on doing both but when I asked her about where my BMI is now and how I would qualify, why couldn't I just resubmit the paperwork?  She said that I could do that.  I call my doctor's office and they scheduled an appoint for 1/22 to get a weigh-in and have another consultation.  My BMI is currently at 41 so hopefully they will not need anything else.  They told me that my 6th month diet and tests were good for up to a year.  I am hoping I can just get weighed in and have them submit the paperwork.  For some strange reason, that just seems to easy but we will see what happens.  The letter stated that I have 180 days from the date of the letter (12/15) to file.  Thanks for listening. Melissa

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