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turned down again

mrbill65
on 5/22/08 11:20 am - Painesville, OH
Well I got tired of waitting and called the insurance company today just to find out that I was turned down again for wls. the only good news ismy wife was approved. They say that my doctors notes for my 6 month diet were not complete, not enough information, I have been doing ww for the last 1.5-2 years and the doctor was aware and we did discuss diet on every visit. My question is since I was turned down on my appeal what is next? the lady I spoke to at the insurance did not know what my options are. Any words of advice. The only good thing is that I have an appointment tomorrow with my doctor. Thanks
(deactivated member)
on 5/22/08 12:04 pm - Canada
I am Canadian covered by my provincial health plan, so I am not sure how much help I can be. However, up here, if we are denied for WLS (which was not my case), I have heard that you keep on appealling until they get tired of fighting and give in

Maybe this works in the US too ...
wlscand09
on 5/22/08 12:29 pm - Tickfaw, LA
Some insurances only allow so many appeals. Then you'd have to get a lawyer or switch insurances. Good luck.
Boner
on 5/22/08 10:57 pm - South of Boulder, CO
Sorry to hear about the bad news. Get your WL surgeons insurance person off their ass and start fighting for you. They need to understand the specific requirements for approal by your insurance company and be your advocate in obtaining approval. Have them find out exactly what is needed for approval then get it done. If the insurance person won't do it (which was my case), do it yourself. This is what I had to do since my WL surgeon's "patient advocate" was a lump. I went so far as to call Aetna's WLS appeals MD, who was in Chicago, to discuss my case.  Best of luck.
mrbill65
on 5/23/08 4:07 am - Painesville, OH
My wife has made this her personal war to get me approved. Even though I feel like I have been kick in the stomach by a horse I have probably given up if it was not for her, She has called the insurance company and she has spoke to her patient advocate, who seems to actually take her calls and will return them. It all comes down to the fact that my doctor did release enough data in his notes. It turns out I do get one more submittal before I get a lawyer involed. Like I said in my eariler post she was approved on the first submittal her doctor apparently wrote a novel for her progress notes, So I discussed all this with my doctor this morning and I think he will be more then happy to provide more information. We discussed alot more then what is in the notes he released. I am just waiting to get the offical notice in the mail before we act on this further. Thanks
Charlie B.
on 5/22/08 11:10 pm - Noblesville, IN
I agree with Boner.  At your doctor's appointment work with them to come up with the next stage strategy. CB

 

 
mrbill65
on 5/27/08 9:57 am - Painesville, OH
well here is the latest update on what is going on. Everyone we talk to as a different opinion on if what my next step should be. My wife gets one answer I get another nobody returns calls it enough to drive a man postal. I got tired of all the BS and called my benefits manager and put her on the case she called the insurance copy and got back to me with in 10 minutes now thats service. The problem is my doctor kept general notes wieght, bp, etc.. while the insurance wants specific diet information. So while I was visiting my doctor for a supervised diet he did not record it in with enough detial in his notes. So I passed this information to my doctor by fax and phone call and I am waiting to see if he can update his notes. Once I get the updated information from my doctor  I am to fax this to my benefits manager and she will fax to the insurance company and they will proceed to certify my claim. So lets see what happens now. So the important thing to take away from this if you are tring to get approval from you insurance company and you need a supervised diet make sure you stress to your doctor the importance of documenting the type of diet and any other conversations concerning the diet. and to include this information in the progress notes. good luck to all. Bill
GoingMobile
on 5/27/08 11:17 am - San Dimas, CA
I believe you can appeal through your insurance, if turned sown, you can then ask for a peer to peer review, this requires your Dr to actually talk to another Dr that works for the insurance company and "sell" them on why you need the surgery, If that fails you can always appeal to the state.
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