Question:
Any advice on how to appeal by telephone conferencing with insurance carrier?

Tomorrow the 19th, CIGNA will participate with me in a teleconference--they gave me no notice; I just got out of hospital and should be in bed--giving me 20 minutes to make my case as to why I should be allowed RNY. Anyone successful at this method; what did you do and what do you suggest for me?(p) I'm 285 # (282 last week), BMI 50 with co-morbs. Last diet was finished July 2002--Atkins; my sister and I--it was not doctor sup'd.(p) You can email me: [email protected] if you have experience (yours or a friend's) to offer.(p) Thanks for your help.(p) Phyllis Moore    — Phyllis M. (posted on August 18, 2003)

August 18, 2003
Contact Lee Ann Krause (a member) immediately!! She had a telephone conference and won her appeal. I am sure she can be of tremendous help. She can often be found on the message board. If not, do a peer search with her last name and you will find her. She has several profiles. I am certain she would be glad to help you. However, you are running short on time. Shelley
   — Shelley.

August 18, 2003
I used to sit on one of these committees that decided appeal cases (not necessarily for WLS, but for any denied service). Believe it or not, the people who decide these things are human, too. We tended to respond more positively to people who made a coherent case in a calm manner (don't threaten or get upset). Folks who came off as sincere and reasonable were much more likely to get a positive response (of course, the case also had to have merit). So, be as HUMAN as you can. Outline the comments you want to make (why this surgery is important to you, how you meet all of the established criteria), but don't write out and then read a speech. You are more of a person if you talk to them, rather than read to them. An impassioned, well-informed, and well-organized plea, based on facts (and a little humanity) is the way to go. Tell them that you need this surgery to improve your health--mention your specific co-morbidities and explain how the surgery will improve them. Say something like you want to be around to see your kids grow up, and your grandkids (if that's true--if not tell them something that is true) but don't suggest that you are doing this for soemone else. Be able to tell them what the gerneally-accepted criteria are for the surgery (at least 100 pounds overweight, BMI of 40 or greater, or 35 w/comorbs, inability to maintain weight loss through traditional methods, presence, or likelihood of developing co-morbidities), and how you meet or exceed those standards (how much overweight are you, what co-morbs do you have, how the quality of your life will be improved, the kinds and number of weight loss attempts you have made in the past--be specific about what diet and exercise programs you've tried over your lifetime, how much you lost on each (or estimate if you don't have records), and how the weight comes back every time). Demonstrate that you understand the surgery is not magic, and that you know you will have to work at weight loss and maintenance, but that WLS is the one tool left that will make that not only possible, but probable. Mention that obesity is a complex disease that is not well understood by the medical community, that 96% of obese people are unable to take off and maintain significant weight loss (per a National Institutes of Health study), but that the vast majority of WLS patients are able to lose substantial weight and keep it off. Ask for the chance to be one of those people. Let them know this is a last resort for you, that you've tried very hard to lose the weight by conventional methods. I'm rambling now, but I think you get the idea. Best wishes to you. Be yourself.
   — Vespa R.