A Friend needs help

A dear friend was just denied by Ohio medicaid because her BMI wasn't high enough (her's is 41, they require at least 50). The surgeon's office won't appeal because they told her it was futile. My question is: Has anyone appealed a denial from Ohio medicaid and won? If so, what was the reason for denial and how did you overcome it? what type of letter was written and what kinds of justification were used? She's very upset and also angry at the surgeon's office since they won't help her. Any ideas what she can do? Thanks in advance for the help, Julie Surgery 02/13/04 down 103 lbs.

There is never any harm in appealing a denial. You would only be out a little time and energy. Your friend needs to do the same as anyone else with any other health coverage. First, she needs to find out exactly what is written in the Medicaid documents about coverage for WLS. If she has a BMI of 41 and some significant co-morbid conditions, they may approve her request, depending and how the surgery is covered. Justification is based on what the plan says. The focus needs to be on how she does meet criteria. She needs to explain how this surgery will save money in the future by lessening or stopping the effects of whatever co-morbid conditions she may have. And, don't forget to include the fact that it would be foolish as well as dangerous to have to gain weight in order to have surgery, when having it with a BMI of 41 means the surgical risks are lower. You really can't blame the surgeon's office for not being much help. If they took the time to find out exactly what they need to write for every insurance denial they received, it would take up a lot of their staff's time - and that is time away from the day to day things they are being paid to do. My philosophy is that people need to help themselves. If your friend doesn't want to step up and find some answers for herself, and appeal the denial herself, then there is nothng else that can be done. I had an abdominoplasty a month ago, and my surgeon was no help when my insurance denied coverage. However, I wrote my own appeal letter and did my own research and was approved. Tell your friend to get started and go for it! Sue

Ohio Medicaid's written requirements are the same as the NIH criteria except that they require a comorbidity. I have seen people with a BMI less than 50 be approved, but not much less than 50. I would say that if your friend has at least 2 significant co-morbidities (sleep apnea, diabetes, and hypertension are the most likely ones to get you there) it may be worth appealing. Your success rate will be higher if you get one of the obesity advocacy lawyers to help you. Good luck, Dr. C The Deaconess Surgical Weight Loss Center Cincinnati, Ohio (513) 559-2545