My second insurance appeal - any suggestions?

    Hi everyone!

This Thursday I have my last doctor's weigh-in to HOPEFULLY finally meet my insurances requirement of six months documented weight loss with no gain.  This will be my second insurance appeal.  Please, if anyone has any statements, ideas, suggestions, words of advice, or anything you can think of for me to add to a letter of appeal that might help my case, and that I might be overlooking/forgetting - please let me know.  I'm getting desparate! 

I have lost my 10% weight loss requirement and hopefully my doctor has enough chart notes this time around.  I'm working on my appeal letter over the next two days, Dr. Oh's office is hopefully putting all my information together again, and my family physician is pulling up all my chart notes.  Will fax all to insurance company by Friday morning.

Please pray for me that all will go well this time around.
Thank you all for your wonderful help and support!

ragadolly/Donna

Well...I don't have any tips but I will cross my fingers for you.

Dr Ohs office should know what is needed.

Best Wishes!
Denise

Hi Denise,

I'm running out of time to do my appeal - just had 180 days to do my 6 months dieting requirement and get my papers all back in - Have my last weigh in on Thursday and my 180 days for appeal ends next Monday on the 20th of April.  So now quickly writting up the appeals letter for my doctor to sign, gathering all my chart notes from my family physician and physical therapist, weigh****cher information, and also writing a personal letter to the insurance company.  I'm running my legs off!  I called Dr. Oh's office to see what else was needed and the front desk gal told me to gather all my updated information and bring it to her on Thursday afternoon after my last  6 month family physician and weigh****chers weigh in.  She said she would then write an appeals cover letter and fax it to my insurance company along with all my previous doctors notes, testing, and information to make sure insurance receives it all again. 

Biggest problem is the Doctor's Oh's office and staff just can't personally keep up with all the different insurance companies and all the different requirements.  They vary significantly from program to program and are based on what your company/work place - has contracted through the insurance company to provide.  Such as Boeing Traditional Insurance through Blue Shield Regence is very different from other Blue Shield programs.  There's just no way for a doctor's office to know it all.  So what I've learned from this process is:  You have to do most of the collecting yourself to make sure you get just what your individual insurance plan requests - plus your insurance can change from quarter to quarter which mine did and can present you with new required information.  It all can get very confusing and be one big pain in the you know what.

So this time around, I'm trying to more than cover all my basis and gather as much information as I can from everyone else and their insurance hassels to make sure I'm going above and beyond this time so HOPEFULLY they can't deny me again for lack of information.  I have learned the hard way that more is better.

Thank you for your reply Denise and I sure hope you are up and around now from your DS surgery.  Are you back to work yet?    How are you feeling?  Is the weight coming off yet?  Please keep in touch!

Donna/ragadolly

Have you written a letter yourself?  If not, I'd suggest doing so.  Include references to primary medical research, the reason you need the surgery, why you will succeed, etc.  You need to be a "real person" not just another file to the insurance company. 

I know a woman *****cently won an appeal after the second denial.  I can ask is she'd be ok with sharing her letter.

Amy

Hi Amy,

I have sent insurance company two personal letters in the past and I will definitely write another one to go along with this package.  This time around I am even writing my doctor's appeal letter to the insurance company and then my doctor will sign it.  It's about 4 typewritten pages which doesn't include my weigh in's and doctor chart notes.  Those will be attachments.  The appeal states thus far, what WLS books I've bought and read, the Obesity Support Groups that I have attended, Obesity Help and magazine that I'm a member of and subscribe too, my weigh****cher progress charts, what I have done and am currently doing for exercise, where I will be getting my WLS vitamins and supplements, measurements, etc. 

I'm racking my brain out to figure out what else I need to add this time around.  If your friend would be willing to share her appeal letter - that would be fantastic!!! 

Do you know of a great source for the references to primary medial research?

Thank you so much for your help Amy!

ragadolly/Donna

I have some links to primary medical research; but they are mostly VSG related.  What type of surgery are you having?  If other than VSG, I'd suggest going to that perticular forum and just posting a request for links to primary medical research.

I've sent a msg to my friend and will let you know what she says.

Amy

just wanted to offer some support and with you lots of luck.  take care!

Thank you so much for your kindness.  I've gotten quite a few replies and some great suggestions.  Am busy re-writting my appeals and feeling much more hopeful now.

ragadolly

Hi Donna!  The only other things I would add to your appeal letter,and to have your PCP document are any comorbidities that you might have such as hypertension ,diabetes, sleep apnea, or degenerative joint disease (arthritis). I also had to submit my food and exercise logs during my pre-surgery diet. I realize the Boeing Traditional requirements have changed since then. Why don't you call the info line and ask specifically what information you need to include in your appeal letter ? I hope we can chat tonight at Merriou's. I haven't been on OH much lately. Work has been especially exhausting and stressful lately. I had a lingering cold, and haven't been exercising much at all. I can't wait to get my energy level back. Hope to see you tonight! 

Hi Pam,

Thank you for your advice.  I have sent them all the information before about my co-morbility problems - I have all the ones you listed plus a few more.  I will include the again in this letter.  Every time I call the insurance company and my Boeing rep - they tell me the same darn thing - read the policy and criteria for the surgery.  I've done that plenty and then I call them back and say "Hey" it's really not spelled out clearly and try to pluck more information to them, with no avail.  I never even could get a good clear straight answer to what medically supervised structured and documented weight loss  with no gain is.  I am going to call my Boeing Rep again in a second and take your advice on asking just what is needed in the appeal letter.  Maybe I will get lucky and she will have an answer to that. 

Thank you again for the information and I look forward to seeing you at Merrilou's meeting tonight.  Take care of yourself - don't want you getting further stressed and don't want your cold to worsen! 

Donna/ragadolly