Appeal Question

Hi, My insurance company is requiring the 6 month diet for approval.  I havent received the formal denial letter yet.  They were waiting to see if I had more documentation.  My surgeon has written a letter saying basically "That is it!".  So we should be getting the denial soon. My PCP wrote a second letter for me indicating that I had had 6months plus of dieting within the last 1 1/2 years.  They said it wasnt good enough because the information did not come directly from the physician/patient notes. I plan to try to appeal (meanwhile I have started the physician documented 6 month diet).  My question is this...if I appeal now and still dont have any luck, will my chances be affected in the spring when I finish my 6months.  At that point, I would resubmit all of my information and try again.  It just seems to me that it is worth a try....unless there is some reason that this would make things more difficult later. Any opinions??? Thanks, Linda

Actually, that's not really true.   First, your appeal now will have nothing to do with a new submission by your Surgeon.  AND, it is recommended that you do that so you have two bites at the apple. Second, diet history is the most common type of denial to be reversed on appeal.  Write a good appeal letter, and have your PCP give you a better more detailed diet history report,  While you're appealing you'll complete the diet, and then if you are denied, your surgeon will re-submit and if denied you can submit the new diet information. You have nothing to lose but a chance to appeal.

Let us know what you're going to do, but I can assure you that you are in NO WAY flogging a dead horse, and NO ONE, NOT ONE PERSON should be told not to appeal a denial. Would you hire a lawyer or pay someone to appeal? No.  Why?  Because a reversal is going to be tougher at this point.  Is it absolutely worthless to appeal,  NO.  You'll end up with either an approval or a final denial, and that denial will say, resubmitt with diet history, and you can either send them the info if your appeal is not closed, or have your surgeon re-start the process.

Thanks for that info.  I felt like that is how it should be and that a appeal should not affect a new request for approval.  I am now doing the 6month diet with documentation by my PCP, but planbly be get my appeal ready at the same time. I appreciate this more positive approach. Linda

Linda, Listen to Gary. He got me approved. Read my profile if you like. Steve

Steve, I have all my appeal information together, but still waiting on 1 piece from my PCP.  I am taking Gary's advise and hope to mail it in this week.  Thanks for your support. Linda