Appeal Process

Does anyone have any suggestions for some more info to send to my ins. company for the appeal process. I sent some documentations of my diet history and some ststistics and about to send some statistics on the savings and cost of the surgery. Is that enough or what else should I send? Thanks

Why were you denied?  What you need to send them will depend on the reason for the denial.

Kelly

The insurance actually has an exclusion in the plan. Its through my husbands employer. So I had to write the ins.company a letter explaining why I think this surgery is so important and the benefits of it etc. and then once I sent in this information last week, they just sent me a letter stating that they are researching my inquiry and they are currently doing research and will send a decision letter within the required timeframe, and theywanted me to send more info include in my review if I would like, so I figure I'll send them some statistics on the costs and savings for the surgery and write another brief letter with that. They did give me a reference number and thanked me for letting them know of my concern, and they would be glad to resolve this as quickly as possible. So hopefully I can send more info before the weekend, and see what happens. Thanks for asking.

Oh.  I hate to break it to you, but if your husband's employer has an exclusion to WLS, they aren't going to cover it, no matter what you send them.  The thing is, the employer opted to save money by not including WLS in their plan.  They have not payed the premiums for WLS.  Since you aren't paying for those premiums, they won't cover the surgery. 

Kelly

Maybe not but I sent a letter and documentations of the savings they would recieve from the surgery and the outcomes  of the cost and savings of each. So I'm expecting they will deny. Once the letter is sent I will still appeal to his union. I'm not giving up until all options are exhausted. You never know I may still have a chance. I have seen many people go through this process and have succeeded. Not that I will but I will try.

Hi,

I'm in the same situation, except it is my employer who has the exclusion.  My best advice.... APPEAL, APPEAL, APPEAL!!!!!!!!!

If the insurance company repeatedly denies you, you can contact the State Department of Insurance and appeal to the Insurance Commissioner.  That's what I'm planning on doing.  I know I'm in for a battle, but I'm not going to give up!

Good luck!!

Thanks Allison for your reply. Humana just sent me a letter stating its denied not because of it being a medical necessity but because of the exclusion. I was expecting them to do that, so now I have documentation of the denial, and now I will appeal to the Union. The insurance company stated I can do a second level of appeal,and once thats done if it still is not granted than I can file a civil action suit against the plan. So now thats my plan B is to send all of my info I sent to the ins. company and what ever else I want to send to the Union and they wont review it until Jan.14th when they have there big meeting. So heres hoping. Thanks again. I hope yours goes well. I'll pray for you.

Good luck!!  I'll be keeping you in my thoughts and prayers.

Don't get discouraged if it's an uphill battle.  I know-- easier said than done, but that's what I keep telling myself! 

Arm yourself with letters from every physician you see on a regular (and not so regular) basis.  If any of the physicians you see are not familiar with the type of surgery you want, educate them about it and then ask them to write a letter of support.  Also have the results of any pre-op testing you've done.  When going into the appeal, the more information you are armed with, the better.

And don't take no for an answer!!

Allison

  (This smiley's hair makes me laugh every time I see it)! 

Has there been any update on this?

I'm in the SAME SITUATION. I'm covered on my husband's insurance by the company he works for excluded WLS from their plan.

Please HELP!