appeals

  Has anyone appealed and got approval from that appeal?

If so, would you share your appeal letter and whatever else you submitted to be successful?

This is what my denial says:

“It was determined that the criteria for medical necessity were not met and the requested service is denied. Rationale: Documentation did not demonstrate a substantiated attempt at weight loss within the last two years, as required my medical policy."

MY argument with this statement is this:  I have seen my PCP for 4 months "physician supervised diet". My doctor's notes from my visits is substantiated.  And isn't 4 months "within" the past 2 years?!  The policy doesn't say "DURING the past 2 years, or Over a period of two years".  It says WITHIN.  The definition of within is:
1. not beyond in distance, time, degree, range, scope, etc  2.    in the inner part of; inside The definition of Substatiate is: : to establish by proof or competent evidence 
I sent Weigh****cher's food logs.  What more proof would they want?
 




 

Will your surgeon's office help with the appeal?

I was denied initially because my insurance company would not cover inpatient services for lap band surgery.  The surgeon's office submitted the appeal saying that it would be outpatient surgery and I was eventually approved.

I would also try to get your PCP to write a letter.

Good luck and let us know how it goes.

Katie

This denial is all about policy.  My insurance does cover lap band and will cover inpatient if there is medical necessity.  I will be having gall bladder surgery the day before and hiatal hernia repair the day of lapband, so they may keep me overnight. 

My PCP will write a letter for me.  She's on vacation right now, but she has told me should would do whatever it takes to help me get this done.  She's wonderful!  I am going to talk to my surgeon's office too. 

Thanks for the encouragement!  I know it will happen sooner or later; I just don't want it to be later!  Patience is not one of my strong points.