Should I appeal?
on 5/5/11 9:03 pm - SC
I have Compass Rose Health Plan (a federal employee plan). My brochure states bariatric surgery is cover under the following conditions:
"Surgical treatment of morbid obesity (bariatric surgery) – a condition in which an individual (1) is the greater of 100 pounds or 100% over his/her normal weight (in accordance with our underwriting standards) with complicating conditions; (2) has been so for at least five years with documented unsuccessful attempts to reduce under a doctor-monitored diet and exercise program and (3) is age 18 or older."
I finally got through all the testing and such with the DR and my precertification was requested, and the insurance is asking for proof I did a 6 month supervised plan within the last year. That's not what the brochure states. Further, I called and spoke with multiple people (getting multiple interpretations of the policy and none of them would provide me with info in writing). One of the answers I got that I agree with was that as long as I had a monitored plan (of any length) within the previous five years, I would be covered. I submitted paperwork with a 3 month plan from 2008.
I give all this background because I have a feeling I am going to be denied. I recently started to visit the Dr monthly while doing weigh****chers just in case, but I don't want to wait another 4 months. The timing would be bad. Is there any point to appealing the decision based on misleading information in the brochure and misinformation from the customer service reps? I appreciate any insight.
If you are denied, and need the surgery (which you obviously do otherwise you wouldn't be doing it!) then you need to appeal. But use your doctor as a HUGE crutch for appealing. They know what to say and what to do. Insurance agencies usually deny the first time anything comes across their desk. (My Dad worked as an insurance agent for 25 years!)
on 5/10/11 3:44 am - SC