Appeal Hearing/External Review

A few weeks back I posted that I had been denied by my insurance company and had an appeal hearing. I went to the appeal hearing on the 4th and was informed a few days later that by a vote of 3-0 my appeal was denied. I had based my appeal on my plan's published bariatric patient selection criteria which states that a patient who has a BMI over 60 with co-morbidities only needs to show 6 months of demonstrated compliance in treating said comorbidities with no medically supervised weight loss required. I felt that, having a BMI of 62 and being a type II diabetic along with a family history of heart disease, I met the above listed criteria. The appeal panel felt different, however, and denied me. Now here is where the plot thickens. The next day I emailed Gary Viscio, an obesity lawyer in New York, who has had the surgery and does insurance denials. He gave me his literature and his fee, and told me to gather certain medical records and send them along with my credit card number and we would be on our way. The same day, I called my insurance company and requested "external review." In Indiana, you have 3 steps. One, the original request. Two, if your initial request is denied, an internal company appeal hearing. Three, if your appeal is denied, you may request expternal review. External review consists of your medical records and your insurance policy along with your certificate of coverage and the company's decsion being reviewed by an outside, 3rd party, Independent Review Orginization. By Indiana State Law, external review is final and binding on you and your insurance company. I had been really busy at work and hadn't checked my mail for a few days. Last night, I went to the mail box and inside I found two letters from my insurance company. The first one dated Nov 8 was the appeal denial from the appeal panel stating the reasons for my denial. The second, dated Nov 12 read as follows: November 12, 2004 Dear Mr. R: X-xxxx has received your request for external review and has re-reviewed your file prior to submission for external review. Based on the Plan criteria for an individual with a BMI>60, you qualify for coverage. Your compliance in treating your comorbidities for at least 6 consecutive months qualifies you for coverage without physician supervised weight loss therapy. Our appeal panel was interpreting the criteria to require your comorbidities to be "uncontrolled" with treatment but this is unclear in the criteria as presently written, therefore the appeal decision is reversed and X-xxxx hereby approves your bariatric weight loss surgery. Sincerely, Xxxxxx Xxxx, General Counsel Can you say Yahooooooooooooooooooooooooooo!!!! I have come to the conclusion that there are two types of bariatric patients: the ones who have their surgery approved quickly and rather painlessly; and then their are the ones who are denied and have to fight like hell. Don't get me wrong, for the people in the first category, I am happy for you and am glad your were approved. For those of us in the second category, I am proof that if you are denied, do NOT give up. I strongly urge you to hire an attorney like Gary Viscio or other lawyers who do insurance denials. Ultimately, I didn't have to pay for a lawyer, though I was only one day away from sending him his retainer. Lawyers like Gary, also have an "EARLY INTERVENTION PLAN." For a mere $225, this program is for clients that are beginning the approval process. Whether you are thinking about having the surgery, have applied for authorization or are awaiting a decision, this program is aimed to help increase you chances of first time approval before ever being denied. This lets your insurance company know from the outset, that you will not simply run and hide if you are denied, and have already taken steps to protect your rights. If for any reason your request is denied and you wish to retain his services for the appeal, that fee is fully applied to the balance of the appeal. If you do get denied, his fee is $450 and he has been very sucessful in overturning denials even if the company has an exclusion provision. If you can't afford an attorney, again do not give up. I had not yet hired a lawyer and I won. And I was denied twice. If you are denied, go to the library and get on the net and do your research. Get your policy and read it cover to cover. Prepare your argument based on medical need and applicable case law such as the americans with disablities act. Make sure you exhaust your appeal process. Many people simply give up after they are denied the first time. Make sure you seee it to the end. I wish you all the best in your insurance battles and in your journey to life long weight loss. All the best, Tim R.

Tim, Congratulations on your approval! Most plans allow for an external review as the final step in the appeal process. Everyone should read their Summary Plan Description (Medical Benefit Plan Booklet) very carefully. The appeal process is outlined, and is not a secret. Best wishes for a gifted surgeon, great drugs, no complications, and a honeymoon period that lasts forever! Roberta