Denied!

Not surprisingly, my first appeal to Premera Blue Cross of Washington was denied. I received the letter yesterday. As a base I used the "bones" of an excellent appeal letter I found on this forum, and then I filled in the blanks and added lots of information about myself, including direct appeals to the insurance company. It was a very thorough letter. I also included copies of every single study that was sent to me by the kind folks at Pacific Laparoscopy. My appeal was reviewed by "one of our Medical Directors" and "an outside speciality reviewer who is board certified in surgery." The outsider reviewer "specializes in laparoscopic procedures including Bariatric Surgery." The decision was "to deny benefit coverage under the plan for a Duodenal Switch (DS) procedure as an experimental and/or investigative service." Having talked at length to Anne (hi, Anne!), I know that it's pretty much par for the course for insurance companies to scoff at appeals. So I was pretty much expecting them to tell me that DS is voodoo or no better than having Uncle Vinnie perform surgery in the garage. However, I also know that people have been denied with the first appeal and then accepted with a subsequent appeal. Can someone give me any great suggestions for how to get my second and last appeal accepted by Premera Blue Cross of Washington? Thanks, Craig

Craig, this forum has a lot of good information on it but it sounds like you need to head over to the Insurance Forum for more specific help on your appeal letter. I hope it will help, good luck to you getting your approval. Hope it doesn't take too long! Molly

Experimental?!?! GIVE ME A BREAK!! I hate insurance companies, I tell ya. I would talk with your surgeon in addition to the folks on this board. They deal with this mumbo-jumbo all of the time and should be able to help you as well. Good luck with everything!! Sheesh, experimental....whatever.

Sounds to me like an excuse to not approve you . DS has not been done much in our area , yet , but it is hardly experimental . This kind of stuff just ticks me off . I'm sorry you got denied . It sounds like you are going to keep trying , which is good . Check out the insurance forum , they might be able to help . Kathy

My insurance company won't approve the DS because of the same reason, but they had no problem with RnY.