Can you help me with an appeal, please??

My boyfriend (BMI ~ 45) found out last week that his insurance company denied him for the sleeve because it's "experimental," blah blah blah.

My question is:  If you were denied and successfully appealed, can you tell me specifically what you sent in to the insurance company for the appeal?  Also, if you can share the letter you wrote to them, that would be awesome.

I am sure this question has been asked before, but when I tried to search, I couldn't find anything as specific as what I'm hoping to get.  I did find a current study on the effectiveness of the sleeve as a stand alone procedure, which I will use. 

Thank you so much for any help you can offer. 

Lori

P.S.  I don't know if it matters, but he has a United Health Care PPO plan in Texas.

Lorilane:

Hi there, I have UHC PPO and live in Maryland,first thing I would do is check the Certificate of Coverage and see if his insurance is goverened  by the State of California Department of Insurance.  Then follow the appeals process outlined in the letter of denial that he has recieved.  Check the state law of Texas in regards to wls.  Some states have it as a requirement and there is case law that supports that the laws of the state where the insured resides can not be ignored.

I have recently sent an appeal to UHC to get the exclusion on my policy overridden due to medical necessity. 

Keep us update, Hope this has helped and if you search for letters of appeal on the site you may find some examples.


If there is any thing else I can assist you with let me know.


Zells_lori is "abuddingrose"

Your boyfriend will not get the sleeve.. Doctors know that the only reason people want it is because they will be able to eat more in the long run. This is not what WLS is for and so they insurance companies refuse to approve this procedure and call it experimental. Tell your boy friend if he really wants to be healthy, take what ever surgery he can get.

I disagree...that is not the only reason people want to be sleeved!  It is a safer surgery first of all and it is much less invasive. I have physical resrictions keeping me from getting any other form of WLS. Maybe you should research alittle more before you make such a negative statement. No matter what form of WLS you choose, you will only get out of it what you put into it. 
It is difficult to get the VSG approval from the ins companies but it can be done with alot of persistance so don't give up and just appeal,appeal,appeal. If I can help at all just PM me. I'm currently going though the process myself.

Good luck,
Tiffany

You should check the DS board as well. I know some of them have fought & gotten approval for the DS which the 1st part of it is the sleeve. I too want to get sleeved. I have BCBS IL & I'm worried that they won't cover it. Someone with my same insurance on the DS board fought & got covered for it. I plan to ask her when the time is right. There's also a woman on Youtube who fought w. her insurance company to get the DS but wound up getting the sleeve. I think her name is citygirl or something. HTHs