Question:
Has anyone been through the external reivew process?

I was wondering if anyone has been through the external review process after being denied. How long does it take and what does it entail? Cheryl    — glowin40 (posted on September 15, 2006)

September 15, 2006
You choose an External Review Group and submit your information to them. They base their decision on medical necessity. What I did was write a letter to the board. I didn't give my life's story because I was told that isn't what they are looking for. What they do want to know is why you need the surgery. I told them my BMI and weight, how long I had been obese, I gave a whole list of my co-morbs including out of control diabetes, acid reflux, joint aches, back pain, Lymphedema, Edema or swelling of the legs... I mean I gave them anthing I could think of. Then I put a picture of myself a couple years ago next to a picture of how I look now. The older pictures showed me with a tan and healthy looking and the now pictures show me bloated and swollen and looking sick. I gave them pictures of my swollen legs. I sent pictures of me sleeping with my CPAP machine and pictures of my abdomen swollen from Lymphedema. I sent them letters from any doctor or specialist I have seen stating I need the surgery. Including my PCP, my surgeon, my chiropractor, my OBGYN, 2 orthopedic surgeons and a physical therapist. I gave them background of family history health. My Grandfather, brother, 7 year old nephew and Dad all had cancer. Heart attacks from Father, uncles, etc. Anything I could think of concerning my family. I sent reciepts of where I had joined a gym, taken exercise classes, gone to TOPS and Weight Watchers. If anything was overkill, it was me and my info. By the time I was done with that package it was clear that I had tried every diet, done my research, exercised and there was also no question that I was obese, sick and needing this surgery. The package gets submitted and the External Review Board made up of health professionals looks it over and decides if Gastric Surgery is needed to get you healthy again. These people don't work for your insurance company so they have nothing to gain by giving you a denial. They have nothing to gain or lose by approving you. So they just base it on how badly you need it and give you an answer. The External Review is where you want to be. It's your BEST chance to get approved because they are NOT your insurance company. So give them all you have!! I knew 15 days after they received it. Yes, they approved me but right before I got the answer my insurance company was switched. The lawyer I hired didn't get the package in quick enough. Now I'm going to go through it all over again myself. I wish you the best of luck!!! Sandy
   — Sandy~Diamond