DENIED

I have been denied by my insurance company. My policy at my company states that it is a covered benefit if it is medically necessary. Medcost says I do not fit within the guidelines set forth by the NIH. Does anybody know what those guidelines are? Please help. I am appealing....any tips?

The only facts I know and the requirements vary slightly depending on the insurance company. You have to have a BMI of at least 35, usually if you have comorbiditys like diabetes or sleep apnea that helps to get approval. The request from your doctor must state "Medically Necessary" or they will automatically deny it. You can always request a copy of those guidelines from your insurance provider. I hope this helps, good luck to you. Don't give up.

Here is the link to the NIH web site - this is where I got a copy of the NIH requirements. http://health.nih.gov/ Hope it helps. Sherrill

Basically, the NIH guidelines require you to have a BMI of 40 or greater with no co-morbidities, or a BMI of 35 with co morbidities. The insurance company may be eluding to the dieting failures that the NIH recommends you have been thru before pursuing surgery. Do you have a copy of your denial letter yet? It should state specifically the reason that you do not meet the definition of medical necessity. If it doesn't, write the company and request that they give you a clearer reasoning of why you were denied. Make sure you send the letter registered, return receipt requested, and follow up to make sure they respond. Fight the good fight! Roberta