Insurance DENIED before surgery consult...PLEASE HELP
I have my first surgery consult today at 4 and and I open my mail at 12 and I have a "DENIED" letter in the mail saying,patient does not meet medical appropriateness criteria for approval.The guidelines enclosed say: HCO will consider requests for gastric bypass in appropriate members who are well motivated, well informed, and are acceptable to operative risks. The member must have a BMI of 40 or more, without a significant co-morbidity, or a BMI of 35 with one or more co-morbidity. Then it says: Procedure 1. Surgery is not first line treatment for severe obesity; members must have documented physicians directed participation in non-surgical therapy for a minimum of 12 months. BUT I DO have a BMI of 40 or above and the documented medical dieting. If anyone can help me PLEASE e-mail me at [email protected] I need help with an appeal letter, and any other information someone may have for me. Thanks.
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