Appeal

I  feel like I have been on a roller coaster ride!

The surgeon's office called Friday to tell me they had gotten an approval and authorization number.  Today my insurance called to tell me they will be overnighting me a denial letter. Despite the fact that the insurance member services confirmed coverage and then reviewed my coverage with the surgeon's office another day and even told them things that they require to determine medical necessity.  I have already had the psych eval, dietary consult, and consultion with the surgeon.  My records were submitted for approval and were reviewed last wk and approved.  They are now saying that I have an exclusion to bariatric surgery.  ?!?!??!  After all that!

Does anyone know if it is ok to do the first appeal yourself or should I go ahead and hire the obesity law group now?  Also I have read some posts saying their insurance only allows one appeal.  My HR "thinks" I do not have a limit but cannot give me find that in writing so I a concerned that I will have my first appeal denied and then they will tell me that was my only shot.   Any advice is greatly appreaciated!

Did your Dr get anyhing in writing or have any proof they approved the surgery? I have worked in Insurance (not medical) for many years and from my experience if you approve something and find out later you made a mistake. To bad so sad you made the mistake your stuck with it. I would hire someone to help you.

HTH

On Friday the approval/authorization was given and the doctor''s office was told that a letter has been sent.  It has not arrived yet.  I am hoping it got out before the insurance changed their mind yesterday.  The doctor's office is supposed to call me when they get the letter.

I am just waiting on so many things!

thanks for your reply!

Hmmm interesting question about self appeal versus hired support.  In my case - I was denied 2 days ago for VSG due to being invesitational.   I decided to call Anthem Blue Cross PPO of CA and notify my intent to appeal.  I had no idea when I called... my appeal would be transcribed and submitted for review by the appeal dept - all over the phone.  I did not have to submitt anything written.  They send you a transcrip letter of your appeal from their board along with a # for your records.  In any case... I'm not sure a lawyer is neccessary with the 1st appeal.  I'd save that for your second appeal when it quite possiably could be done in person or perhaps with a state judge as I've heard some say.   In any case... most certainly appeal.  In my opinion, the letter of 1st approval is a legal document that you could use very well in your appeal.  To me that approval letter is just that - I "INSURANCE COMPANY" will pay for all services rendered - dated xx-xx-xxxx.

I wish you success for a positive outcome....

- To Be Me again

Thanks,
Did they tell you how long the appeal process will take?
Good luck to you too!

By CA law - the appeal proccess / response is within 30 days from date of appeal.

Thanks DTNASH.... right back at you!!!

If you have all the documentation of who spoke to who on what date and the information that was confirmed to who that can be put in the appeal along with you request for an appeal.  I would most certainly 1st try to appeal on your own and then if you keep hitting brick walls then contact an obesity lawyer.  If you have any questions or need help, PM me I will be glad to assist you anyway I can

Thanks so much!  I do have all the a dates and who spoke with who.  I still have not gotten the denial letter that was supposed to be over-nighted to me on Tuesday and it is my understand that I can not appeal until I have the denial in writing.  I did receive the approval letter on Friday.  !?!?!?!  

The local HR person told me the first step before an appeal is to request a review through employee services which I did last Wednesday.  I hope to hear back from it any day.  Today I sent an email with all the crazy details to the HR person over the division  my husband works in.  I hope he will send me a response tomorrow!  Prayers for positive feeback are greatly appreciated!

Thank you to everyone for your support!  This has truly been a crazy mix up and an emotional rollercoaster ride!