1st Appeal Denied Cleveland Clinic Employee Health Plan

Has anyone had any dealings with the Cleveland Clinic Employee Health Plan insurance? What about the "financial counselor" at the Cleveland Clinic (Baritric Dept)? What about the name of a good Ohio attorney specializing in helping the appeal process with the insurance companies?  This outfit/insurance company (in my experience) is absolutely terrible. The appeal was submitted on 4/14 by the financial counselor and the insurance company sent the denial letter the same day.  Any help or advice from those experienced would be most appreciated.  I have 45 days from 4/14/08 to file another appeal. They are saying "I do not meet the medical criteria".  *Note: I am 5'2" and weight 230 lbs.  I have allergies, asthma, hypertension, GERD, Hiatus Hernia, etc... I probably have osteo arthritis along with sleep apnea but have never been diagnosed. My BMI has been 40 plus for the past year with an exception in 1/07 on a visit to the allergist where they have me at 5'4" and 216.7#.  I wear my hair on my head in a clip, a business suit, and small heals daily.  I have never been asked to take my hair down and shoes off to be weighed! I feel the insurance company here is trying desperately to find a reason not to pay for this surgery regardless.  Do I have any other options (other than self pay which I cannot afford).  Please help...I am so upset and disheartened.  Thanks!  Lisa

Different insurance companies have different requirements on what qualifies as "medically necessary", so I would suggest that you first get a copy of their clinical bulletin that has their criteria for medical necessity and be sure that you do, indeed, meet the criteria (some policies count things like hypertension, for example, but some do not).  Once you have that, you can address their policy point by point identifying how you meet the requirements for BMI and comordbidities.  You might need to GET an official diagnosis for the sleep apnea (a sleep study) and/or arthritis (simple xrays) if that will help you document the comorbidities.  Pay particular attention to the length of time required for the BMI.  EVen if you ahve one occasion where the BMI wasn't quite high enough, if you can show (from your PCP's records) that your BMI has been over the requirement for longer than required, they will probably ignore a one-time weight where it wasn;t high enough (after all, how often have we all lost some weight only to gain it right back?). Good luck. Lora

Thank you so much for your reply Lora.  I sincerely appreciate it.  My PCP office is now putting together all visits from 1/07 through 3/08 where height and weight is documented. This will then be faxed to the insurance company per their request. Hopefully this will help. Thank you again! Have a great day.

Walter Lindstom is supposed to be a great atty with WLS. I would google the name and get his website. he is also reasonable from what I hear other people say.

Thank you so much! I was doing alot of searching through this website and noticed that name also. Funny you mentioned it.  I did contact his office this morning and they got back with me this afternoon. They seem to think they will be able to help me.  I sent alot of documentation to them as well.  I will keep everyone posted in case someone else may need the help also.  *Note: I did receive a call this am from the financial counselor.  Now my 1st appeal denial is "still open" provided I can submit height and weight history from 1/07 through 3/08 regarding all visits to any physicians (not using Cleveland Clinic Epic computer system - My Chart). I did go to my PCP and requested this information.  It should be ready tomorrow. Please say prayers as I am hoping this ends it.  However, if not - I will be utilizing Walter Lindstrom.  Thanks again!  I sincerely appreciate your response.  Take care.  Lisa