Question:
Any suggestions for appeals to ins co. after a denial??

I have been doing preop testing, groups, appointments, etc since April 2008 and just last week my insurance denied coverage for my Lap RNY. I feel somewhat discouraged although I was told to almost expect to have to appeal. When I called the ins co to discuss my appeal, the lady said, "well, unless your BMI changes, you won't qualify." My BMI is 39.4. How insane is that?? Is she suggesting I pig out and bring that number up?? I can't STAND THE THOUGHT of gaining another pound!! Any thoughts would be appreciated... THanks, Anna    — cristeen7 (posted on February 2, 2009)

February 1, 2009
You're not stating you weightjust your BLM in this question you have asked! :No one wants to have gain in order to have surgery. However, maybe, you should consider 1. going to a nurtionist 2. Paying out of pocket if the doctor allows 3. Insurance is very strict on their rules. the reason is because people won't try to loose and this is why insurance goes up ...People want an easy fix and this is a life time change for those who can't loose.
   — Eneleh

February 2, 2009
I was denied BUT.. I regrouped and got a letter from my primary care doctor, gynocologist, and chiropractor. resubmitted with a letter from me and was accepted. Good luck!
   — sueannel123

February 2, 2009
I was denied twice. In July 2005 I weighed 361 lbs. with a BMI of 60.1. I was super-morbidly obese but not sick enough for appproval. My high BP was controlled by medication, I became pre-diabetic, under went knee surgery because the weight was crushing my knees. I started writing letters. I sent them regular mail and registered mail. I begged for them to approved the surgery so that I could get my life back. I asked all of my doctors to write letters. My bariatric surgeon did not write a letter in my behalf but my orthopedic surgeon did (actually I wrote it, he signed it that seemed to get their attention. Finally after a tough fight I will be having my surgery on 2/4/09. I'm lookin forward to starting my journey towards a better life. Don't give up...stay on them. btw I have GHI.
   — Cookie1257

February 2, 2009
Anna, You stated your BMI but not your weight. Insurance companies generally need a medical reason like most physicians do to perform a procedure. It may have nothing to do with you. One thing I would suggest doing is research in finding a bariatric surgeon who will tell the insurance company that it is a MEDICALLY NECESSARY procedure to save your life. I had to appeal mine back in the "dark ages" to get the surgery done myself some 21 years ago. Insurance companies are in business to make money so that is why they are so strict. If you are a high risk to start with they usually don't want to take the chance to heal you. Sad but true. I pray daily for an answer to this unhumankindness. I will pray for your answer to come swiftly in the positive, vinnigirl, retired RN
   — vinnigirl

February 2, 2009
When my doctor started me on the path to approval, my BMI was right on the cusp of the typical insurance cut-off. He actually recommend that I not try to hard to lose any weight until after I was approved, just in case that was the deciding factor. As it turned out, I was approved within a week, anyway, because I was already diagnosed with Metabololic Syndrome, which is basically one step away from Diabeties. I've no doubt that was what sealed the deal for me. Depending on your health in general, it could still be reassessed. Best of luck.
   — suezahn4me

February 3, 2009
ObesityLaw.com they are wonderful and helped me fight my insurance denial and won.
   — Pam_B_OR

February 4, 2009
File a complaint with the Department of Managed Health Care (DMHC). Here is the link: http://www.dmhc.ca.gov/if you are in California. There should be something similar for each state. A contact from the DMHC may just sway your insurance carrier to approve your surgery. Worked for me plus the pre-op weight loss/program requirement was waived. Good luck!
   — amanda_g