Question:
Insurance DENIED before surgery consult...PLEASE HELP

I have my first surgery consult today at 4 and and I open my mail at 12 and I have a "DENIED" letter in the mail saying,patient does not meet medical appropriateness criteria for approval.The guidelines enclosed say: HCO will consider requests for gastric bypass in appropriate members who are well motivated, well informed, and are acceptable to operative risks. The member must have a BMI of 40 or more, without a significant co-morbidity, or a BMI of 35 with one or more co-morbidity. Then it says: Procedure 1. Surgery is not first line treatment for severe obesity; members must have documented physicians directed participation in non-surgical therapy for a minimum of 12 months. BUT I DO have a BMI of 40 or above and the documented medical dieting. If anyone can help me PLEASE e-mail me at [email protected] I need help with an appeal letter, and any other information someone may have for me. Thanks.    — Lynda T. (posted on August 9, 2001)

August 9, 2001
If you have the information to prove their denial was wrong then submit that and make sure all the information they need is there.. make sure your Drs chart notes go in showing the supervised diets you've been on, make sure you include a list of those you've done on your own w/ the outcomes etc. I wishy ou great luck!!! I can send you a copy of my appeals and originals letters if you want.. email me at [email protected]
   — Dawn R.

August 9, 2001
You know their remark about a patient being "motivated?" Perhaps they are testing your resolve? First and foremost, look at your insurance policy manual and find out how long you have before you have to turn in an appeal. Then, write them a letter formally requesting the criteria they used to base their denial on. Important, make certain to write in that letter that this is not your appeal letter. Otherwise they will count it as one. With that criteria in your possession you can see what criteria you didn't fulfill and work to find the information or proof that you in fact do. Sometimes they will deny if you didn't send them copies of the pertinent records showing you are qualified for this surgery. Prepare your appeal with every scrap of information you can find regarding your medical records and dieting history. Then, get your pcp to write them a letter stating you have fulfilled their criteria by having the high BMI and the medicallly supervised diets. Perhaps what they are wanting from you is for you to be on a medically supervised diet for 12 months? This is shuck and jive, trust me. When you find out what their criteria is, you can refer them to the NIH guidelines and show that you in fact meet those guidelines and that is what they should base their criteria on as it is the prevailing standard. Go to www.nih.gov and run a search under Obesity. I hope you can get your approval because it sure sounds like you qualify to me. If you get another denial, try using a lawyer. BTW, I am not a lawyer, I have been battling my insurance for about 4 months. Good luck!
   — Diana M.

August 10, 2001
I fought my insurance company for 5 months! Don't give up, keep at them I got two denials and did an appeal to the insurance company, had lots of tests to satisfy them, finally they approved me! DON'T GIVE UP!!!!!!!!!!!
   — cynthia E.