DENIED - TRYING TO APPEAL

I'm trying to appeal a denial letter that was sent to me on October 4, 2004. I believe that my doctor just sent the notes from my visit with her, and not a REAL letter. This is what I have gathered so far: The denial letter The notes from my doctor's visit of 9/22/04 A letter from Henry Ford Bariatric Center saying what codes are needed to be included in the letter (from the doctor) My complete blood workup of 9/22/04 My Weigh****cher's chart from 7/99 A description of diets, medications, OTC's, nutritionists, memberships from 1983 to present A weight chart complied from private journals from 1978 to present I am getting trying to get a letter from outside of the Henry Ford Network / Health Alliance Plan from a doctor that has know me since the early 1970's. He knows the family's health history and has treated me when I could not get in to see my PCP. Any suggestions or comments would be most apprecated. I would like to get this letter of ASAP. I don't want to with anyone, just get my surgery approved and get the ball rolling! Rhonda

Rhonda, The additional documentation you send with your appeal should support your contention that the REASON you were denied was in error. You don't mention why you were denied in your post. Here are my (infamous) Do's and Don'ts of Appeal Writing: DO indicate the reason the claim was denied should be refuted, with the original denial wording used quoted in your appeal letter. DO specifically link all medical studies to the patients individual situation. DO highlight Medical records submitted in your appeal as to doctor treating (name), dates, diagnosis, treatment, etc. DON'T beg your insurance company to approve surgery. When you show weakness, they want to go in for the kill. There's nothing more wonderful than the smell of fear or pity to make some burned out insurance company rat get excited. Rather, write a good factual appeal letter, pointing out where they erred in their decision. Support your facts with good documentation from your attending physicians. (Your medical records.) Keep it as objective and non-emotional as possible. all personal, subjective statements should be removed. The denial will be overturned on the merits, not sympathy. DON'T ever take anything the insurance company says over the phone as accurate. Demand that all correspondence be in writing. Get a copy of your policy, since they may quote a policy provision that isn't even in your policy. THIS IS CRITICAL. I can't overstate this enough. DON'T fax an appeal, or any added documentation. Rather, send it certified, return receipt requested, or overnight so that you have proof of receipt. ALWAYS send a copy of your appeal (in the same manner) to the Vice President of Group Medical Claims. Be sure you indicate on your appeal that copies were sent to the VP, the Insurance Commissioner in your state, (unless it's an ERISA plan which isn't governed by state law.), and all of your physicians. DO use good grammar and spelling. Have a trusted (intelligent) friend proof read and edit for you. You don't want your typos or poor grammar to distract from your intention to sway them to your way of seeing things. If you are not a good writer, consider having a friend, consultant or attorney write the letter for you. THIS IS YOUR LIFE! DO request that the appeal be reviewed by an outside, 3rd party physician reviewer if the appeal is not overturned internally. If you are on an ERISA plan, you have the right to appeal within 60 days of the denial. The clock is ALWAYS ticking. DO request the names and credentials of the insurance representative *****viewed your records, and copies of the specific records that were reviewed. Also request copies of any "expert medical opinions" secured by the company in making it's decision. ALWAYS keep a detailed log of when you called the insurance company, the date and time, the first and last name of the person you spoke with, the questions you asked and the answers you were given. This is imperative! Fight the Good Fight! Roberta

It's always a good idea to send copies of all your medical records that support your diagnosis of morbid obesity, diet history, and all co-morbid conditions from the last 2-5 years IF you were denied due to medical necessity.

If I sent them my complete medical history, we would be talking about a file 8" thick! It seems that everything is now being done electronically....