Denied and need to Appeal, will someone help!

I just got word from the doctors office that I have been denied. I need to appeal now and I need some help. Is there anyone out there that is willing to help me. I have no idea where to start. The doctors office told me during my very first consultation that the people who make the lapband will fight the denial......for free? I'm lost someone help. They did tell me to call 1-877-lap band  before i do any suggestions?

Why did they deny you? Was it denied all together, or just the lap band? (Will they cover RNY?)

Letter of denial basically stated that I was denied because I haven't had a BMI of over 40 for at least 5 years.

Hi again Ashley, I just read this additional post of yours.  Did you have a BMI of 40 before 5 years ago?  Did the highest weights from each year get submitted?  Do you have any other co-morbid conditions like diabetes, sleep apnea?  You should qualify with a BMI  of 35 with one of those.  If you don't mind telling what is the insurance company?  This is a common loop hole used by some and there can be some ways to address this. Take care, Mary

Ashley is only 22, and I doubt she could prove a BMI of over 40 during her teen years....

Hi Mary, I was denied for the same reason.  I currently have a BMI of about 41 and 3 co-morbidities, however 5 years ago my BMI was 33.5 and I didn't have an co-mobids.  I haven't gotten the records from my doctors office yet, but I think the first co-morbid (Hypertension) happened about 3 years ago. My insurance says I either have to have the 40 BMI for 5 years or the 35BMI with co-morbids for 5 years.  If you have anything that can help me with my appeal, I would appreciate it.   Sorry Ashley, don't want to steal your thunder, I hope Mary can help both of us! Thanks Sherri

HI Sherri and Ashley, I really do hate how much the insurance companies are using this loop hole lately.  Just tossing out some idea's here.   1.  Make sure when you measure your height that you are not wearing shoes.  Also don't "stand tall".  Many of us do.  I have measured patients just standing naturally as opposed to standing tall and there can be an inch difference.  Well...that greatly helps your BMI.  Also if you were a teen several years ago...I am wondering what your height was?  Maybe you can even go back furthar in your records looking for BMI figures.  You could then argue that you have in fact more than met their morbid obesity history requirement because you can show a longer time struggling up and down in weights.  Recently that arguement was used against Cigna in our office, in a peer to peer review and we won!!   2.  Carefully comb thru your records.  You only need to show one to two weights per year.  PIck the heavier ones to submit.   3.  If all else fails...figure out when your weight did qualify in the past and figure out how much time you need to add to make the requirement.  Then resubmit a new request.  I am the one warped person on our office that cheers when a patient reaches a BMI of 40 or adds  another comorbid condition.  Those things make me smile cause I know you have a better chance of getting approved the first time.  Isn't that sick? Try to smile thru all this. Mary

I was just denied for the same thing!  Please let me know if you get any suggestions that sound helpful.  I am working on an appeal by researching my co-morbidities and their health risks.  Not sure if that will work but is all I can think of. Thanks Sherri

Well, before you start your appeal, I would take your problem over to the WLS light weights forum. People there are more familiar with how to fight the "you aren't fat enough" argument! http://www.obesityhelp.com/forums/wls_lightweights/

Obesitylaw.com will fight for you and the lap band people pay the fee.  Good luck. I was just denied for the  RNY, after being denied for the VSG.   I hate insurance.