Question:
How can I get my surgeon to send an appeals letter on my behalf?

I completed every test that my surgeon required and was still denied by BSBCNC for controlled hpn. The coordinator also submitted me for lap band surgery instead of the RNY surgery. Also, I had an additional comorbidy that was not filed with my original paperwork. No appeal letter to date and it is going on 2 mos since denial. I am receiving hospital bills for all of my tests which total approx. $4,000 which I can not afford to pay. My coordinator has not returned any of my phone calls to date. Do I have to take legal action to get this ball rolling?    — Kareba (posted on December 6, 2009)

December 6, 2009
I was told by my doctor that I have to do all of the work to get the appeals started. Yes you can have your doctors write letters and stuff but it falls on you to get the ball rolling with the insurance company. I am so sorry to hear you are facing all of this but do not give up and just keep fighting the insurance company most of them want the person to give up. I thought I was going to have to fight mine but I got lucky and was approved on the first try. Just do not give up and keep fighting and call the insurance compnay and doctors daily until you get the answers you need. I called my insurance company the day my file was submitted and everyday until they had an answer for me. FIGHT them.
   — lscheller

December 6, 2009
As soon as I knew I was denied I started the appeals process. I knew only I could make the best case for me because no one else knew my history better than I did. I called the insurance co. number on the denial letter and made sure I understood the exact reasons for denial. I "googled" "Weight loss surgery appeals" and found a couple of excellent sample letters that I used as a basis for my own. I got official copies of my BMIs and labs. I wrote a 2 page letter that stated all the "corrected information" (just like you have), how that did meet their criteria, then some heartfelt paragraphs about my struggle with weight loss for the last 30 years, etc. - even made ME wonder WOW - how could you turn that person down when I proof read the letter. Then I called and asked where to fax it and explained that I had several corrected facts to present, they didn't even want the letter to go to appeals then but back to the original medical policy office which meant even less time (2 weeks instead of 4) that they would promise to get to it. After I faxed my letter I called to be sure they got the fax (it was the day after Thanksgiving) then I called again the following Monday to be sure it was recieved in the correct office - the woman told me she would check on that and three hours later she called me saying the denial was reversed. Total time between original denial, and reversal - 1 week!. I was literally shaking with disbelief and relief. It was a whirlwind experience but well worth it. Don't expect anyone to fight your battle for you. If you need help, your primary care doc is more the person to go to than the surgeon. Because the surgeon does the procedure and, well face it, benefits financially from doing so - it isn't really ethical for that person to try to argue with insurance companies; does that make sense? I also thought the person who submitted the less than accurate information from the surgeon's office should be involved more but frankly, my attitude was, if I wanted it done right, I'd just do it myself! Never give up, especially when you are right. Best Wishes.
   — Lakesidemom

December 6, 2009
Why would you want to take legal action against someone who will have your life in their hands? Most surgeons want to get you approved so they will have the income, I think you just need to make some calls yourself to BSBCNC and speak with one of their patient advocates. You are ultimately responsible for any testing which your insurance isn't covering, did they tell you why they are not paying for it? BCBSIL paid for all my testing before I was approved for my surgery.
   — rkurquhart

December 11, 2009
I just had my denial overturned. It cost me a relatively small retainer (WELL WORTH the $600) and I couldn't be happier with ObesityLaw dot com. I do not work for them in any fashion, I just want others to know there is a way to get the help you need.
   — SeattleBiggie

December 11, 2009
ALSO: If your doctor won't help you and write a first level appeal letter - fire the jerk. It sounds like he or she is more concerned with the insurance company's opinion of them than in your health and well being. They are supposed to be a help to you, not a hinderance.
   — SeattleBiggie