Question:
I need help appealing to Healthlink Great West on an age restriction (25).

I was denied by Healthlink Great West (being reviewed by One Health Plan) because they have an age requirement of 25. I am putting together my appeal letter and need some help on how to address this age issue. I am 21 (22 in May) and know that my health will be much deteriorated by 25 if I don't get the surgery now. My surgeon will not see me until I am approved, so they tell me I am not a patient of his until I see him and cannot help. My PCP has no openings until June to see me (that is too late) and I can only speak to her nurse on the phone. My doctor doesn't return phone calls because "she has to pick up her kids at school at 3 and doesn't have time to call." I told the nurse the situation and she said that she didn't know if my doctor would be comfortable in writing an appeal letter. I think I am relying on my letter alone (as I will not use Walter Lindstrom until absolutely necessary, I cannot afford him) to appeal this. Please help! You can email me if needed. I would appreciate it! Thank you! Erin [email protected]    — Erin Z. (posted on April 2, 2003)

April 2, 2003
http://www.obesityhelp.com/morbidobesity/m-instrouble.phtml
   — Kasey

April 2, 2003
Sorry to hear that you got denied. I also have Great-West's One Health Plan insurance and they had denied me originally for not being medically necessary and for not meeting the age requirements. I would strongly recommend involving your HR department at work. That was what I had done and they were and continue to be nothing but supportive of me. They had alot to do with whether or not I would beat that clause of theirs. Also, double check your coverage booklet. My company wrote letter after letter disputing the claim of needing to be over 25 because in our booklets, nothing was ever mentioned. So, why should Great-West feel they can include their own exceptions without notifying anyone? They used the same reasoning as you...If i need heart surgery, do I need to be a certain age? I also wrote an appeal letter of my own. After all this was done, it was after about 3 or 4 weeks of my file being "in review" that I was told to get an endocrine study and a psych eval done (so if you haven't done em yet...get it done so you'll be ready!). After they received those things, I got approved. So, it is possible to do! Also, Heather Russinko of this site was also denied for that reason...being under 25 and had beaten that as well. Don't worry, the surgery will happen for you as well!! Good luck with it and if you need any help, please email me and I'd be glad to assist any way I can!!
   — Christie N.

April 2, 2003
duh...i was also going to say that I was 22 when going for my approval (23 now). Heather was 23 during this as well. And my email addy is [email protected]. good luck again!
   — Christie N.

April 2, 2003
Erin, here are some tips for writing you appeal letter: First, avoid being emotional. Second, spell out how having this surgery now will cost the insurance company less than waiting to meet their age requirement. I would call and find out why they have that age requirement. Was it just something arbitrary they came up with? Do they have any statistics or information to back up this age requirement? If so, what source are they using? If they don't, you can pretty well shoot it down as having no logical basis! If they do, you need to fight fire with fire and find statistics to refute their source. (I am betting that this is arbitrary, though.) If you have co-morbid conditions, or the possibility of co-morbid conditions (family history of diabetes or heart disease, for example) include that. It will cost less to pay for your surgery than to pay for complications of diabetes or heart disease down the road. I would be happy to help you with a letter, email me if you want. You are better off writing your own letter. The doctor may be supportive, but they usually write something along the lines of "she is appropriate for the surgery and in my opinion, is a good candidate". Not exactly what you need! Good luck!
   — koogy

April 3, 2003
The difference in my health from when I was 21 to where I am now (25 1/2) are scary. In just two years I became almost immobile and have been trying for the past two years to get better. Since being 21 I developed high blood pressure, was diagnosed with sleep apena, my legs became grotesly huge with fluid and skin folds because of lymphedema. In the past year I have been in hospital 3 times. I'm not sure how this would help you but OMG the insurance needs to realize that 4 more years can be harmeful to your health and more expensive to them!
   — Sarahlicious

April 3, 2003
Hi there...I havent been around in a while, but I fought Great West on their age resrtiction this past May and won. I wrote a letter along with a written appeal explaining that preventing me from this surgery until I was 25 could only increase my risk for other co-morb's and possibly death. I included an extended family history of heart complications, obesity, infertility, ect. I cc: the letter to the state commissioner and to the local government here. It really got the ball moving. Dont give up, they can be tough. Oh, and once you do that....call 3x's a day - no matter what they say. You have that right, and it will make them want to try to get rid of you faster. :-) ****Hi Christie**** Heather
   — hrussinko