Question:
Appeal letter - Need advice

I probably worked harder on my Letter of Medical Necessity than anyone can imagine, spending literally day and night on it from mid-March until mid-June, when I submitted my packet. It was more like a legal brief, and the Letter of Medical Necessity alone is 15 detailed pages long. I used the sample letter on this site, deleted what didn't apply and GREATLY AMPLIFIED what did. I left no stone unturned, i.e., made many many trips to hospitals to sign release of records for ER trips over the years, surgical procedures that related to Obesity, etc. Didn't rely on my PCP for any of that, although she did write a good augumentation (I even orchestrated that!) - this is too important for us to not be 100% proactive. Even the best physicians are cramped for time. Bottom line, there is absolutely nothing else I could submit, with the exception of a trip to my Orthpedic Surgeon made after I sent in the packet, where he declared me a candidate for total knee replacement, and actually recommended bariatric surgery for that co-morbid alone. I see the sample appeal letter on this site, and it is entirely redundant with the sample Letter of Medical necessity;it also recommends that one include the original paperwork sent in in the 1st request for authorization. If I do that, they will basically have a duplication of what I originally sent in, (plus the new stuff from Orthopedic Dr, of course.)My question is this: given the fact that I've already covered every imaginable base (copies of all reports, diagnoses, proop of medications, many attachments etc), should I just wait for the denial, and concentrate on whatever specifics they base their denial? I want to have an appeal letter ready to fire off when the denial comes, but have nothing else much to add. Thanks so much for your help. Pam Cerda    — pam C. (posted on July 10, 2002)

July 10, 2002
Pam, What makes you so sure that you will be denied? It sounds like you have clearly covered the medical necessity requirements the best you can. With your thoroughness, I also bet that you covered your past diet attempts. Is there some requirement that you are sure you do not meet? Is there an exclusion in your plan? If you know of something specific that will be a problem, you may want to consider how to address it now, but if you don't it makes no sence to write the appeal until you know on what grounds you were denied.
   — Amber L.

July 10, 2002
I too am convinced I will be denied. I have found a web-site : www.obesitylaw.com. It has lawyers who have been through this process many times. It says in their website, you can hire them for $500 or less and they have a very high success rate for getting denials reversed. There is an info. part you can fill out for them to call you for a free quote after you tell them your problem.
   — Amy S.