Need Info On Appeal

Hi all.     Hope everyone had a nice Christmas & will have a wonderful 2008. As most of you know I have been denied. I have BCBS. My denial stated not medically necessary. My plan does cover it & states if you are 100 lbs. over weight & bmi over 40 you do not have to have co-morbidities. I do not have any serious co-morbidities but am 150 over & bmi of 47. I have met all the qualifications required. Had psy. evaluation, been obese 5 yrs. + lost 10% & everything thing else needed.     My surgeons office has been no help. They do not handle appeals. My surgeons office stated on their  denial letter, tit said here was question about my 10% loss. I lost 32 lbs. in 3 months. My letter only said not medically necessary. I did not have to do a 6 month diet just loose 10%. I dieted so hard & did the liquid diet 3 days before my 3 monthly weigh ins. That is the only way I lost that fast. I was so determined. It has been a year since I started this journey & yes I have gained every ounce back. So, if that is what they are questioning I can't prove anything. I can't believe they would think my doctor would lie if that is what they were saying. That is the conclusion my caseworkwer & I thought it sounded like. If, they had questioned it a year ago, they could have sent someone out to weigh me or send me somewhere else to weigh. Oh, my caseworker said my diet, exercise program & documentations were well explained.   My question is what do you think I should do about that? If, anyone has done a appeal especially with BCBS give me any advice. Haven't sent yet but, I wrote a good letter on the 10% weight loss & stating a copy of where it said I didn't have to have co-morbidities if I were 100 lbs over or bmi of more than 40. Do you think I need to send copies of completed requirements again with this letter or will they pull them from where my surgeons office sent them in? I tried to get copies from my surgeons office & they wanted $'s out the butt. I can't believe they wouldn't want to help me in any way. They wanted like $20 for first few pages & then so much for each page after. I can't remember. I was so stunned I just blocked the conversation.   If, anyone has been through a appeal please send me any infomation. You can reply here or send me a personal message. For the record I have been dealing with Dr. Madan's office in Memphis. He is moving to FL.  Has a awsome partner but they are of no help. They are excellent surgeons but are no help with approvals. I wish I had gone with Dr. Weaver in Memphis but don't think they will take me on to help with my appeal.    Sorry this is long but any advice is welcomed. Thanks Ellen    I

I say gather up your medical records from all your doctor's offices, find a new doctor who handles appeals!  Write a letter of appeal and state to them everything, the date, how much you weighed, how much you lost and on what date you were re-weighed, present all medical records to them also... if you cant find a new surgeon.

Ellen ~ First of all, you have a right to your medical records! And if they have not given explanation of their policy of $$ for copies before now, I would fight them hard on this - in person, if need be. another option would be to talk to Dr. Madan's partner (or his nurse) and see if they can help you get your records since they're in the same offc and you will now be a patient of theirs. If they help you, you might consider staying with them. If they give you the same run around, I'd pay for the copies ( after making a BIG stink), and find a new surgeon! Then I would make copies of all the documented information - dates, times, etc. - and send it with the letter you wrote explaining your weight/BMI are in accordance with their policy. (Make sure you keep a copy of everything in case you need it again!)  You never know, but I would be prepared that they may wnat you to re-lose your 10% (just so you're not emotionally thrown for another loop!) And remember --- you're not doing 'this" or doing "that" for bcbs... YOU'RE DOING IT FOR YOU!!!!! Keep that thought ever before you in the front of your mind! It's not about them. It's about YOU!   Now, don't you wish I'd tell you what I really think - ha ha!  Good luck, sweetie, and STAY STRONG! ~ Tara

Tara...you really need to work on saying what you think.  LOL  You are a little wishy washy! Ellen: Something very similar happened to me.  I started my process with one surgeon and got denied twice.  When they didn't help me...I packed up my paperwork and changed to another surgeon.   Tara is absolutely correct in that you need to get copies of all of your paperwork and then be prepared to start the process over if need be.  I firmly believe that everything happens for a reason...we don't always get to know what the reason is but God has a plan for each of us.  Just keep trying, Sweetie! Good Luck!  Freddie

Ellen, I agree with all that has been said  before.  Don't give up.  A web site that I found very handy was the Obesity Action Coalition.  They have great resources and suggestions to help you fight the denial.  A page on the site I found really interesting dealt with appeal letters.  It actually gives you examples of letters to write as well as a lot of other important information. Hope this helps!  I am keeping a seat saved just for you!

Thanks to all of you for your input. Scott you are a lifesaver. Thanks for the links. I will gladly research them. Ellen

Have you had a sleep study?   I do not have any significant co-morbidities either so surgeons office suggested I have a sleep study and guess what..I have apnea...Most overweight people do and this is considered a biggie in the ins world..but I do not know for sure if this will do the trick for me as the surgeons office just submitted my claim today...It would be worth a try!!

Hi Chrissy,   Yes, I had one because my surgeon requests one. I do not sleep good at all. I either can't get to sleep for a hour or two or if I go to sleep good I wake up for a bathroom trip & stay awake 2 to 3 hrs. At my sleep study I took a big dose of night-time nyquil. I did not sleep. Got up for 2 or 3 bathroom trips & took a second big dose at 3 am. They told me I slept a total of 10 min. I know most was because of the strange place, the night vision camera watching me & scared to move because of the attached wires. I know if I had another one I would do the same. Are any of my sleep problems above signs of sleep apnea? Ellen

In light of your denial I would try to repeat the study...They obviously didnt get enough info to determine if you have apnea or not...I was so uncomfortable that I had the tech put me in the recliner and finally I went to sleep...I was only asleep for a couple of hours, but it was enough to determine I have apnea....I work in a hospital and had my sleep study there...the bed was horrible..so horrible in fact that I complained to the administrator and they bought new ones...But when I had to go back for C-pap titration I had my doc give me an ambien...This was before the new beds so that had nothing to do with the fact that I slept...Not wonderfully mind you but enough that they were able to get a good study...I slept about 6 hours that time...So try an Ambien...it knocked my socks off...I don't think I could have stayed awake with a gun pointed to my head...It was crazy to be so sleepy so quickly...If the facility did not get enough info you should be able to have it repeated...I think they are required to have a certain number of sleep minutes recorded to bill the ins company...an adequate sleep study could be just what good ole BCBS needs....If anyone has told you that you snore you probably have some level of apnea...Good Luck

 

Ellen,

I woud just agree with all here,  try the OAC links that Scott gave you.  I am so glad that you are going to appeal and not let the insurance win.  Let me know if I can do anything for you.

darlene