Need advice on how to appeal...

Hi! This weekend I found out that my insurance company has denied my pre-approval for lap-band surgery based on the following: "there is no documentation to support the patient has life-threatening co-morbidities that have failed medical management. There is no evidence the patient has tried a physician-directed weight loss program for 18 consecutive months." It is true that I do not have an co-morbidities at this time, but they run rampant in my family! It is only a matter of time that I will have heart problems or diabetes if I don't get this weight off. It seems like they would want me to be near death before they would approve. Also, it seems like the surgery would be more cost effective in the long term if they approved it now instead of waiting until I have a co-morbidity that has failed medical management. Also, I have not been on a doctor supervised diet for quite a few years, and even then it was not 18 months. Insurance doesn't pay for doctor supervised weight loss programs! But, I have been counseled about dieting by my current PCP for my last 3 years during my yearly exam. Anybody have any advice on how to file an appeal in my situation? Would I have any luck by having my current PCP write a letter stating that he has counseled me? Thanks! Steph

I would request a copy of the company's internal guidelines for approval, and specifically what medical evidence their requirement for 18 months of supervised dieting is based on. I think it's absurd.

Thanks for the reply! I will call the insurance company tomorrow. It did state in my denial letter that their determination was based on the following guidelines: Milliman & Robertson, Apollo, and ICM Corporate guidelines. I have found the Milliman & Robertson guidelines defined on the web. I meet the criteria for this guideline. I have done a search for the Apollo guidelines, but cannot find them without paying $65 to see them. And the ICM guidelines would be internal to the company that determines if the procedure is medicallly necessary. Do I have a right to call and ask for a copy of these guidelines? I also thought that 18 months was absurd. I've been trying to diet my whole life, but I can't seem to stick to the plans and I always end up failing! This surgery is my last hope! Thanks again. Steph

No offense to anyone, but I used a lawyer. Pure and simple. Gary Viscio at www.obesitylawyers.com I do not believe that they read anything unless it is legal. My first lawyer was a wreck. Gary at least had the surgery and knows his stuff. Fight hard.

LOL

You absolutely have a right to those documents. Call them and tell them to send you the documents right away. I dare them to show any guideline that states the 18 months of a supervised diet is medically necessary. Tell them you want to see EXACTLY what that requirement is based on, and not just the title of a document. Let us know what happens, Fight the good fight! Roberta

Okay - I just got off the phone with the company that does the medical reviews for my insurance company. They require an 18 month doctor supervised diet becuse they want to make sure that you can eat the right way and conform to the strict way of eating after you have surgery. Don't they get it - I want the surgery so I can no longer eat the way I do!! My options are as follows: they can send out my current info to an outside doctor and have him make a determination. Or I can send additional information to them, and they would forward the old and new info to an outside doctor to make a determination. If I get another denial, my appeals process is done with them. I would have to go back to my insurance company and fight them. I asked if this new doctor would be following their same guidelines. They said no, it is an independant doctor that does not work for them and will follow the national standards. Things maybe don't look as bad as I thought they did. I may have hope yet! I'm going to get to work on my appeal letter and get it out ASAP!! Steph

THIS IS JUST MY OPINION, IT SOUNDS LIKE YOU ARE ON THE RIGHT TRACK. I USED AN ATTORNEY AND IT WAS A WASTE OF MONEY AND TIME. IT SOUNDS LIKE ROBERTA A. CAN HELP YOU WITH YOUR APPEAL. I WISH I HAD CONTACTED HER FIRST. CYNTHIA

Steph, When you write your appeal, ask for the external review. Tell them that you want the reviewer to have everything in your package including your written appeal. Also, make sure you write in the letter that their 18 month EXTRA CONTRACTUAL requirement for dieting is unreasonable. Fight the good fight!! Roberta