Help! Medicaid denied me for no valid reason

Hello everyone :)

My information was sent in to Medicaid and within 2wks, or less, my application was denied. They gave me 4 reasons.

1) my BMI wasn't 35 or greater with co morbidities.
2) Medical record documentation that my high BMI must have been present for the past 2 years. 3) Participation in a physician - supervised nutritional and exercise program for a total of 6 months.
4) Absence of psychological contraindications -absence of reliable support system and personal resources to manage the stress of major surgery and to successfully adapt to the expected lifestyle changes.

Okay, now here is the thing…

 

1)  I have had a high BMI for 5 years (way over 35 and now I’m BMI 42). I wanted to get the surgery many years ago but decided that it was too risky because it was fairly new to doctors at the time, so I backed off. Well in the meantime I got heavier while dieting.

 

2)  My medical records clearly document my high BMI for the past 2 years.

 

3)  I have been seeing my physician for 8 months straight now. I am simply on a low cal diet with smaller portions and exercise. My doctor also has given me meds to take down my high blood pressure and to help with my long term anemia, plus I have asthma.

 

 

4)  I have had my psychological exam (by 2 doctors) and I was approved by both.

When I contacted the Bariatric Nurse Coordinator she looked at my file and saw that I had my 6 months with the doctor, my psy exam, and so on. She says that she has not gotten a denial letter from Medicaid yet but will let me know when she does so that she can explain their excuses better to me.

So here is my question today.....I have 30 days to appeal. What is the best way to go about doing that? In the Medicaid rejection envelope, it had  a VERY BASIC appeals form (Recipient Hearing Form, DMA 2003). I have to basically check X in 2 places and then sign my name and send it back or fax it. It doesn't ask me much else or to attach a personal letter of why I disagree with Medicaid's decision.

What it does say is that I will get a call so that I can discuss why I disagree and that a face to face mediation can occur at a mediation center. If Medicaid's people listen to me and agree with me then my case will stop there and I will be approved for surgery. But if NOT, then the appeals process will continue and then I will have to stand before a judge to make a decision....which he still will send to Medicaid and they can STILL deny me coverage for surgery.

Again, what is the best way to handle a Medicaid appeal? I was thinking about contacting legal aid and possibly getting an attorney, if they handle Medicaid denial cases. Maybe it's best to also have an attorney present during the mediation meeting too. I feel that Medicaid is going to have people at the meeting with a set answer of NO NO NO. It's just a formality so that Medicaid can say "hey, we gave her a chance to speak, but um, still, NO".

A place called - Prior Approval Unit, HP Enterprise Services - sent me this God awful letter. Who is this, just some 3rd party that didn't even look at my packet and medical records?

I'm 38years old. I'm 5 feet tall and weight 220lbs - and NOTHING is working.

God, I just want my life back. I was in law enforcement years ago and now I cannot return unless I'm healthy again. Please help, I have to respond to these people tomorrow (Monday June 28th, 2010)

 

Dear Rose,

I am so sorry to hear of your denial. I would say that it would be best for you to pull the medical information that supports your claims and have that ready for your appeal. I've never done an appeal for medicaid, but did have to do one for Social Security because I was initially denied there for something else. I wrote a letter and attached it to my appeal form. I don't know if that would work for you. 

I would suggest that you consider cross posting this to the Main and Insurance forums, maybe also the RNY forum to see if anyone else has experience with this and might offer some suggestions. 

Many get approved through Medicaid, so I think it is likely that you will as well. 

Hang in there, 

 

Thank you for your response. I have posted this in the other forums as you suggested.

I truly hope this is over soon. I may give it a try by simply sending in a letter with the Appeals form. But like I said before I just have this strange feeling that it's not going to be easy. I don't want Medicaid anymore. I want to be healthy so I can go back to full time work.

It would cost them less in the end by giving me the surgery and then getting rid of me all together. With new work comes new and different health insurance.

I saw a lady on Youtube that said she wrote her insurance company a 15 page letter after they first denied her. Then they approved her. Now I'm not writing a 15 page letter but I still want my say so to prove them wrong.

I would also contact your insurance person at the dr office and talk to her about the denial. It does not sound like all of the information may have been sent to medicaid that needed to be sent.

My doctor just sent my letter for me to have a Gastric Bypass, I had everything, but my doctor said as of the month July 2010 medicade was no longer paying for the Bypass. I couldn't believe it, so I called another place and they told me the very same thing.

The best way to go about appealing Medicaid's decision is to follow the procedures they outline to appeal their decision, even if that procedure begins with checking two boxes and signing your name.
Make copies of any documents you send them for your records and come prepared to the appeal hearing by bringing your documentation refudiating each one of their points for the denial.
I wouldn't invest in an attorney just yet. It would be a waste this early in the game.
As long as you have documentation from your medical providers that you have consistently and frequently attempted to address your health crises with the help of a physician over the past 2 years and you have participated in a program to address your issues with weight loss (not just a doctor's recommendation of diet change and exercise) it certainly sounds like you have a strong case.
Never wait until the last second to address any problems you have with your Medicaid coverage, especially if you are appealing a decision they've made. Your prompt response to anything regarding your coverage, from appeals to completing reviews, shows that this service is important to you and having this procedure is important to you as well.
Keep in mind though, Medicaid is just like private health insurance in that they can choose to stop covering any service at any time. There are a lot of private health insurance companies that do not cover this procedure either, no matter that a particular consumer may need it and pays to be covered by their insurance.

maybe this link can offer some insight:
http://www.ncdhhs.gov/dma/hcmp/NCHC-Surgery-for-Morbid-Obesi ty.pdf