Appeal or Wait

I've been receiveing and seeing many questions regarding what to do if you receive a denial based upon either diet history, BMI, or any type of "must be met requirement." Should I appeal or wait until I satisfy the requirements? I have also been seeing some purely incorrect advice. So, to answer the question, let's explore the possibilities, Ok.  You've been denied.   First, make sure you get the denial in writing.  It doesn't matter what you're told on the phone.  Get it in writing so you can appeal. Second, read the denial.  What were the SPECIFIC reasons for denial.  Do you meet those requirements, such as a 6 month diet, or do you need to start a six month diet.  Maybe your diet records are a bit sketchy but they show a failed diet pattern Depending on the type of plan you have you have a few options. You can certainly not appeal and wait the time to satisfy the requirements under your plan.  BEWARE!!!!  Make sure your policy does not renew or expire within the time that you must complete the requirements, or you could be dieting for six months only to find your plan now totally excludes the surgery. You can appeal.   You have nothing to lose at this point.  And, you do not need to hire anyone.  Just do some research and file an appeal.   Self funded plans - These are plans where your employer pays the claiims and hires a carrier as a third party administrator (does paperwork).  In this case your appeal rights are guided by the wording in the plan.  If you're denied, you can sue under ERISA or, wait until you meet the criteria. In plans where your employer pays ONLY premiums every month, you may have the right at some point to appeal to the State for an independant external review.  In some states, like NY, NJ, CA and PA, you really do not need a diet history of any length.  You just need to show a basic failed diet history.  A well written PCP report will suffice in most cases.   In cases where you do not have an external review, you can still appeal. In either case, self funded, or fully funded, if you appeal you DO NOT WAIVE YOUR RIGHT TO RESUBMIT FOR APPROVAL WHEN YOU MEET THE CRITERIA.   If you are told otherwise, you are being advised incorrectly. If your appeals are concluded and closed, the carrier will simply open a new claim when your Surgeon re-submitts for approval.  If it is still pending, you can either withdraw the appeal or send in the new information under the old claim number and request that it be considered. Again.  There is nothing wrong with appealing while you are trying to meet the requirements.  You waive nothing.  You cause no harm.  Or, would you rather wait out the six months only to find out that your plan has changed in the meantime???