Question:
letter of appeal

I am trying to write my first letter of appeal. My insurance company is denying the approval stating the weight control services and obesity treatment are excluded from coverage under the terms of the Member Handbook, but they failed to include the last sentence "unless determined to be Medically Necessary". Should I stick to the point and send them copies of my member handbook stressing the fact that with my BMI of 53.8 I am considered Super Morbid Obese along with several co-morbidites. They also revised a Medical Coverage guideline on 05/15/06 on the Subject of Surgery for Clinically Severe Obesity stating certain surgical procedures performed for the treatment of clinically severe obesity (bmi >35) my be considered medically necessary when all conditions are met, which I do. Do I give them the details of my health again or do I stick to the point restress all of the facts on why the surgery is medically necessary for me? I don't want them to think that I am insuating they are idiots but I also want them to realize that I have done my research as well. Any suggestions would be helpful.    — PDESPOS (posted on September 28, 2006)

September 28, 2006
hi, I would send them a copy of the paragraph of your handbook and also a copy of the revised guidelines. In your letter i would outline each co morbidity restate your bmi and i would also send a letter from your pcp with copies of your office notes. If all else fails also send a copy of this letter to your states insurance commisioner if they deny you again. I work for a health insurance company and office notes along with a letter from your doctor may go a long way in your case. Good luck God be with you
   — camille1956

September 29, 2006
Go to the search engines and put in obesity surgery appeal letter or something to that nature. It will give copies of appeal letter written, which give you something to go by. Try more than one search engine and you may get more varieties of letters. They are good.
   — geneswife

October 2, 2006
In my appeals letter, I covered the following in a bulleted format: 1. My co-morbidity conditions, the medications I had to take and the impact each co-morbidity had on my life. 2. I wrote about the quality of my life, the impact that my excess weight had on my health, the cost of maintaining my health. I also noted that without my surgery, the cost would most certainly go up as I would develop further obesity health related issues. 3. I would stress to them the "medical necessity". 4. I also found out that our employer had a Benefit's appeal department of which I also sent a copy of my appeals letter. I think this was extremely helpful as they have the ability to overturn any decision the insurance company made. Last but not least, for my protection as was giving so much information to the insurance company, I put the following clause in "ALL OF THE INFORMATION CONTAINED IN THIS DOCUMENT AND THE ATTACHED DOCUMENTATION IS CONFIDENTIAL AND IS TO BE USED ONLY AS IT IS RELATED TO THE REFERENCED PROCEDURE BELOW." Good Luck!
   — MorningGlory