Help! Medicaid denied me for no valid reason

My information was sent in to Medicaid and within 2wks, or less, my application was denied. They gave me 4 reasons.

1) my BMI wasn't 35 or greater with co morbidities.
2) Medical record documentation that my high BMI must have been present for the past 2 years.
3) Participation in a physician - supervised nutritional and exercise program for a total of 6 months.
4) Absence of psychological contraindications -absence of reliable support system and personal resources to manage the stress of major surgery and to successfully adapt to the expected lifestyle changes.

 

 

Okay, now here is the thing…

 

1)  I have had a high BMI for 5 years (way over 35 and now I’m BMI 42). I wanted to get the surgery many years ago but decided that it was too risky because it was fairly new to doctors at the time, so I backed off. Well in the meantime I got heavier while dieting.

 

2)  My medical records clearly document my high BMI for the past 2 years.

 

3)  I have been seeing my physician for 8 months straight now. I am simply on a low cal diet with smaller portions and exercise. My doctor also has given me meds to take down my high blood pressure and to help with my long term anemia, plus I have asthma.

4)      I have had my psychological exam (by 2 doctors) and I was approved by both.

When I contacted the Bariatric Nurse Coordinator she looked at my file and saw that I had my 6 months with the doctor, my psy exam, and so on. She says that she has not gotten a denial letter from Medicaid yet but will let me know when she does so that she can explain their excuses better to me.

So here is my question today.....I have 30 days to appeal.  What is the best way to go about doing that? Should I get an attorney to help with the appeals process? In the Medicaid rejection envelope, it had  a VERY BASIC appeals form (Recipient Hearing Form, DMA 2003). I have to basically check X in 2 places and then sign my name and send it back or fax it. It doesn't ask me much else or to attach a personal letter of why I disagree with Medicaid's decision.

What it does say is that I will get a call so that I can discuss why I disagree and that a face to face mediation can occur at a mediation center. If Medicaid's people listen to me and agree with me then my case will stop there and I will be approved for surgery. But if NOT, then the appeals process will continue and then I will have to stand before a judge to make a decision....which he still will send to Medicaid and they can STILL deny me coverage for surgery.

Again, what is the best way to handle a Medicaid appeal? I was thinking about contacting legal aid and possibly getting an attorney, if they handle Medicaid denial cases. Maybe it's best to also have an attorney present during the mediation meeting too. I feel that Medicaid is going to have people at the meeting with a set answer of NO NO NO. It's just a formality so that Medicaid can say "hey, we gave her a chance to speak, but um, still, NO".

A place called - Prior Approval Unit, HP Enterprise Services - sent me this God awful letter. Who is this, just some 3rd party that didn't even look at my packet and medical records?

I’m 38 years old. I’m 5 feet tall and weight 220lbs – and NOTHING is working.

God, I just want my life back. I was in law enforcement years ago and now I cannot return unless I'm healthy again. Please help, I have to respond to these people tomorrow (Monday June 28th, 2010)

Strange, sounds like you did everything required.  Have you found out anything since your original post.  I am sorry you are going through this.  Surely they just missed something, and this can be easily proven.  Keep us updated.
Kelly