Can anyone show me or help w/an appeal letter for VSG?
Hi Jen,
It is critical to know the wording that was used when they denied coverage for VSG. Is it because it is considered unproven or experimental? Do you have a copy of the policy that they use to determine coverage (note - this isn't the same as your insurance policy. It can be hard to find, but medical providers should/can get access). In that policy it will explain their "coverage rationale".
If denial is because it is considered unproven, some of the references in my appeal would be helpful. I posted it here: http://verticalsleevetalk.com/insurance-financing/1496-my-ap peal-draft-w-references.html It is over a month old now and if I was writing it now I would wait and include the new position statement (when it gets posted) from the American Society of Metabolic and Bariatric Surgeons (www.asmbs.org). Also, sometime in November we should be getting confirmation if, in fact, the AMA CPT editorial board approved a CPT code for VSG at their October meeting. How many days do you have to appeal? Another option is to write your appeal now, then when (if) it is denied, write a 2nd appeal and include the asmbs and ama references. I recently received an email from someone on BCBS that won her first appeal w/VSG, so it is not unheard of, and actually now that UHC and Kaiser in California are approving VSG, it will become more common to win on first appeal until all or most insurance companies get around to updating their medical policies.
Good luck, let me know if I can help.
Luanne
It is critical to know the wording that was used when they denied coverage for VSG. Is it because it is considered unproven or experimental? Do you have a copy of the policy that they use to determine coverage (note - this isn't the same as your insurance policy. It can be hard to find, but medical providers should/can get access). In that policy it will explain their "coverage rationale".
If denial is because it is considered unproven, some of the references in my appeal would be helpful. I posted it here: http://verticalsleevetalk.com/insurance-financing/1496-my-ap peal-draft-w-references.html It is over a month old now and if I was writing it now I would wait and include the new position statement (when it gets posted) from the American Society of Metabolic and Bariatric Surgeons (www.asmbs.org). Also, sometime in November we should be getting confirmation if, in fact, the AMA CPT editorial board approved a CPT code for VSG at their October meeting. How many days do you have to appeal? Another option is to write your appeal now, then when (if) it is denied, write a 2nd appeal and include the asmbs and ama references. I recently received an email from someone on BCBS that won her first appeal w/VSG, so it is not unheard of, and actually now that UHC and Kaiser in California are approving VSG, it will become more common to win on first appeal until all or most insurance companies get around to updating their medical policies.
Good luck, let me know if I can help.
Luanne
Hi Luanne,
First of all thank you so much for responding.
I had to do a quick verbal appeal on October 13th. They originally denied me because it is considered an investigational procedure. They have 30 days to respond back to me. After that I am not sure how long I will have for the second appeal. Thanks for the heads up on getting a copy of the policy. I will be sure to contact my MD to have them get a copy of it.
Is there a certain deadline that the ASMBS and the AMA CPT editorial board will be posting anything? Or how does one go about finding out when a statement or posting will be made?
Thanks again, I look forward to hearing from you.
Jen
First of all thank you so much for responding.
I had to do a quick verbal appeal on October 13th. They originally denied me because it is considered an investigational procedure. They have 30 days to respond back to me. After that I am not sure how long I will have for the second appeal. Thanks for the heads up on getting a copy of the policy. I will be sure to contact my MD to have them get a copy of it.
Is there a certain deadline that the ASMBS and the AMA CPT editorial board will be posting anything? Or how does one go about finding out when a statement or posting will be made?
Thanks again, I look forward to hearing from you.
Jen
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