Not being able to resubmit after appeal denials?

Hey guys, if anyone has any info on this topic it would be MUCH appreciated!  Here is some background on the situation.  I'm currently trying to get insurance approval for Laparoscopic RNY.  My insurance CURRENTLY requires a 12-month physician supervised diet.  I have been told by the insurance company that starting January 1, 2009 this is going to be changed to a 6-month physician supervised diet.  So my doctor's office went ahead and submitted me for approval in June (the insurance company liaison told me to submit even though I had just started my supervised diet).  I was denied.  I spoke to the insurance reviewer and she told me what I needed to do was go ahead and do the 1st level appeal as a formality even though she knew I would be denied again.  Then after I finished a 6 month supervised diet (next month in October) I could go to the next and final level appeal where they include my company in the decision (Principal manages my insurance but it is a private company insurance).  Because they are changing the requirements in January they might consider approving me next month.

Well I just called my Bariatric clinic office to ask them for some paperwork I will need to submit with my final appeal next month and they told me they haven't officially stated they are changing to a 6-month supervised diet in January.  And she also told me that if I exhaust my appeals then I may not be able to resubmit for approval after I officially meet the requirements (whether they change them or not).  So this has me really worried because I want to get this done as soon as possible (hence all the stupid appeals) but I don't want to shoot myself in the foot and not be able to get the insurance either.  Does anyone have any information about whether or not this is true and what I should do?

Thanks in advance.

Kari (in Iowa)

I submitted because the insurance company told me to.  I had 19 years of documention of being overweight and of physician and dietician supervised weight loss attempts.  They told me they would take my extensive documentation into consideration.  However, they didn't and they denied me.

I appealed because the reviewer I spoke with after my denial told me to go ahead with the appeals process because I would finish my 6 month diet a couple months before they were changing criteria and she said they would take that into consideration and possibly approve me.

It's a big giant irritating mess basically and I feel like I am being deceived.

My only question was whether or not if I exhausted my appeals could I resubmit later after requirements change.

Kari

Hi Kari,

I am sorry you are having such a hard time.  Be warned..  Usually once you exhaust all appeals there is nothing else you can do.

I have BCBSIL and they only allow you two appeals before you can no longer do anything else about it.

Take care and Good luck to you..

Chrissy

Hi Kari!

Let me just warn you that depending on your state and your insurance company, you only have so many appeals and once they are exhausted....you're out of luck.  You'll want to check your insurance policy very closely.  Trust me, you don't want to waste what appeals you have left no matter what the insurance company says..They don't have your best interest at heart and they know you only have so many (ususally 2 appeals aprox) appeals.  If you have insurance through your company you'll want to contact your HR person to verify how many appeals you're allowed.  I would not trust what an insurance company tells you about a "New" policy becoming effective on Jan 1st 2009.  If this never comes to fruition then you've wasted one of your appeals.  I am on my 3rd and last appeal (this one goes to my company as their the actual plan administrators).  My first 2 appeals were denied by United Healthcare.  I actually hired the Obesity Law and Advocacy Center http://www.obesitylaw.com/.  Hiring them was the best decision I have made.  They have a 97% success rate for those clients the accept to represent and they have been in practice for about 12 years fighting insurance companies and employeers.  Walter Lindstrom is a guest speaker at many of the national conferences and is an expert in this field.  I can honestly say it has been worth it and even if I don't get approved I'll know that I had the best filing my appeals and protecting me against the insurance company and my employeer.  Good Luck!