appeal process?

My sister is in the process of researching surgery.  She called her insurance company and they said that they won't cover it but she can appeal it.  How often does the insurance company say yes to an appeal?  Is is worth a shot to try?  Should she get her surgeon to help her with the process?  I am hoping that it is worth the effort.  She really needs to have this surgery and it took her a long time to accept that she does and I don't want her not to get it because of insurance problems!

Thanks!
Amy

Check to see if WLS is an exclusion from her employer. Those are hard to fight. Also have her get a copy of her Healthcare plan from HR and get a copy of the insurance companys Bariatric policy. She may be able to find that online.  Information given over the phone is not aways correct. 

I say give it a go. Many folks get appeals approved. It's a long process but with patience, it will be worth it. She will need help from both her PCP and her surgeon. Your surgeons office will probably more familiar with the process.

Good Luck

Amy most insurance will not except an appeal from the provider, it has to come from the patient but can have medical necessity letters from surgeon, PCP, cardiologist etc etc.

She needs to find out if her policy is a fully insured policy or self insured policy she can call her employers HR department and they should be able to give that information

If You Have a Fully-insured Policy
The next step is to resubmit the authorization. For the resubmission process, you will need to know why you were denied. Do not be afraid to call your contact and ask for a detailed explanation in writing as to why you were denied.

Once you receive the explanation, read it carefully. Most times, denials are categorized as either “Not Medically Necessary," “Experimental Procedure," or “Excluded Procedure." If there is something in it you do not understand, call your provider and ask for a more detailed explanation. Remember, you pay for your insurance, so let them work for it. Review your billing codes, and make sure the correct ones were used.

If You Have an Employer’s Self-insured Medical Benefits Plan
The denial probably will occur at the predetermination stage of the process; therefore, you may not receive a formal “Explanation of Benefit" (EOB) form from the provider denying the authorization. In order to submit an appeal, you must receive a formal written denial, usually in the form of an EOB. This EOB should include a paragraph explaining your appeal rights and how to submit an appeal. Such as:

If you do not agree with this determination, you may appeal it in writing to the Pension and Benefits Appeals Board within 60 days of receiving this letter. In addition, you have the right to appear personally before the Board, review pertinent documents, submit issues and arguments in writing, have a representative appear before the Board or present written issues and arguments, and present additional information to the Board.

The denial should also give you a detailed explanation why you were denied, and what specific sections of the plan were used to make the denial.

Do not be afraid to contact the provider to request this denial. Also, if you have studied your plan and feel there is a specific portion of the plan that allows for the treatment, you should ask them to review your denial with this in mind. Many times an insurance company applies the rules they have for their insured products and not the plan rules for the specific employer when making initial determinations.

Once you have received the denial, you should submit your appeal paying close attention to any time limits required by the process.

The laws and regulations that allow a company to get tax advantages for providing employees with medical benefits also require the plan to implement an appeal process. A verbal denial, such as the plan does not cover this procedure does not meet these regulations. If you cannot get a formal denial from the provider, contact your employer’s personnel or benefit department for a formal denial. At the most, the plan must respond to your claim within 60 days or they may not be in compliance with ERISA.

This may sound like a lot of work, but in the end the benefits to your health are worth it.

Avoiding Discouragement
The process of contacting and working with your insurance provider may be a frustrating one. Do not become discouraged. By taking your time with each step and maintaining patience, you will only enhance your ability to have your treatment option covered by your insurance. Remember your rights as a policy holder. Do not be afraid to ask questions and do not forget, as we mentioned before, that you pay for your insurance, so make them work for it!

Morbid Obesity Statistics
These statistics briefly detail morbid obesity and its affects in the United States. Feel free to use these statistics when writing your letter(s) to your insurance provider. Educate them on the affects this disease has not only on you and your quality of life, but also others.

• It is estimated that more than eight million Americans are morbidly obese. Morbid obesity is characterized by an individual weighing more than 100 pounds over their ideal body weight, or having a body mass index (BMI) of 40 or higher.

• Approximately 75 percent of the morbidly obese have at least one co-morbid condition (diabetes, hypertension, sleep apnea, etc.) which significantly increases the risk of premature death. 1

• Life expectancy for a 20-year-old morbidly obese male is 13 years shorter than a normal weight male of the same age. 2

• Annual direct medical expenditures attributable to obesity are $75 billion. 3