Question:
HELP!!! I received my first denial letter from BC/BS...need a great appeal letter

BC/BS ActiveCare denial letter indicating "gastric bypass Not Medically Necessary because there is no documentation of a medically supervised weight loss program within the past 12 months....letter from PCP that I was on phentermine for a year from 01-02...have regained 50 pounds lost and then some..now 280.....help me with an appeal letter?????????    — Pat L. (posted on August 20, 2005)

August 20, 2005
Hi, my insurance Blue cross Blue Shield HMO took the same stance, and they still have the opinion 4 years after I applied for the first time, that gastric bypass is not necessary. They don't want it to be "necessary" because they don't want to "pay" It has nothing to do with whether or not we did need surgery, it's about the money. However, Doctors in the field of gastric bypass are doing their very best to document and prove surgery is necessary, but that is going to take time. My suggestion: what I had to do was obtain financing from my bank for the procedure. I had reached 420 pounds and couldn't wait any longer. I was out of "time". I'm sorry I don't have a more positive answer, in how to change the insurance company policy made by their director boards. Not only would they not even consider the surgery for me, they dropped my life insurance and disability insurance that goes along with my medical poilcy, without telling me. One positive note, they did pay over $15,000 for my hernia surgery I've had to have since the bypass:) I had the gastric bypass Feb 2nd 2005, and I'll pray you find financing for it, it will save your life!
   — mrsbrown42

August 22, 2005
I also have BCBS and am preop. As of July BCBS wants everyone to go through a medical supervised weight loss program with their primary care physician (PCP). At the first visit to your PCP you need to say it is for obesity, preop. Then ask your PCP to refer you to a nutritionist for one visit. Then you keep going to your PCP monthly for 6 months. From what I understand whether you lose weight or not is not a big issue. Just have your PCP document why you did not lose and also document what physical exercise you are doing too. Anyway, it is just an insurance prerequirement before they will approve the surgery. At least that is what BCBS of Alabama says. Get started on your first visit to your PCP, the time goes fast. I have one more appt to go. Good Luck.
   — muffin56

August 22, 2005
Have you filed an appeal? Do you have your medical record copies? You can file an appeal and when you do your appeal reason letter use your medical records to document each date you saw your physician, how much you weighed, and that you continued your weight loss drugs. Document this for each month you saw your doctor and continued the medication. In a new paragraph address any co-morbidities such as diabetes, osteoarthritis, gallbladder disease, sleep apnea, acid reflux, etc. End your letter with a paragraph addressing how you feel you have met the six months of medically supervised weight loss (with success or failure)and request a review of the medical records the insurance company has received. Most of the time a clerical staff member reviews the medical records. If things aren't worded exactly as they have been trained as proper documentation, your application for approval will be denied. With the appeal, a medical staff person will review the letter and medical records and you should get approval. I used this format to write an appeal letter for a co-worker and she was approved within two weeks. Good Luck!!! Cheryl
   — Cheryl N.

October 26, 2005
Pat, PLEASE let me know if you get an actual letter from someone! I am despertly looking for the same. Thanks in advance! [email protected]
   — Shelly S.