Question:
How much medical necessity is enough? ADVICE NEEDED

The claims rep at my ins said that she did not think I would get approved because I did not have enough medical records. They told me when I first called them about the wls that all I needed was medical necessity. I did have a looong letter from my wlsurgeon stating my history, a letter from my knee surgeon stating that I have stage 2 osteoarthritis(i prob blew the sp on this one)and it was caused by my weight and can be helped by wls, and my ob/gyn who did my c-sections saying that wls is a necessity, and finally I had my med file from another surgeon who had wanted to do wls in 1998 (the previous ins denied). So I have letters from FOUR surgeons that ALL reccommend that I have the wls surgery and now the claims rep says she doesnt think that it is enough???? This lady has been kind of snotty since she found out what type of surgery I was having. When she told me that she didnt think it was enough info I said to her "I weigh almost 400 lbs, that in itself should be reason enough." She said,"Well, so do I." Her additude ticks me off...but do you think that 4 letters from surgeons is enough? Please respond...I'm going nuts worrying!!    — cherokey55 (posted on May 26, 2002)

May 26, 2002
I have 14 years worth that amounts to over 50 pages and my insurance still denies me
   — Linda L.

May 26, 2002
Terri - I would bypass (no pun intended)the claims department/customer service and speak to someone on the "medical consultation team." They are usually nurses or people making the decisions about approval or denial. I started out speaking with my customer service department and ended up wasting a lot of time - one CS rep told me all they were waiting for was the psych eval resutls, but when I spoke to the medical review team, they told me I needed all this blood work and an echocardiogram - which took an extra 4 weeks to get scheduled. Sometimes the customer services department doesn't have all the records in front of them. As for the snoody attitude, I would speak to HER supervisor - I think a lot of people out there in the insurance industry need to be educated not only about obesity but also about compassion - you may pave the way for someone else not to struggle the way you have! Good luck!! ~ Carrie
   — Carrie B.

May 26, 2002

   — Payam S.