Question:
Can anyone give me any advice as to if this is a good appeal letter?

   — Dina L. (posted on February 12, 2002)

February 12, 2002
Dina... </p> Let me just say, I can't tell you whether or not your letter will make any difference.. I wasn't fighting an "exclusion" in my policy so I didn't have to get as nasty.. but it's worth a try. perhaps some of this can help... <br> Making an exact chart of the diet programs you've attempted, how long you were on them, and how much weight you lost / regained <br> Finding someone who's had surgery covered by this insurance and ask for a copy of thier bill / reimbursements to the surgeon by the insurance (i.e. my girlfriend had the same procedure I did.. with the same insurance.. I got a copy of her bill which showed what the surgeon charged and what insurance paid for it) <br> If you doctor has a billing company or whoever handles his insurance affairs, see if you can get a list from all your dr's and specialists for bills your insurance has covered for you due to your co-morbids.. Your insurance may have this, but they tend to be kinda selfish with information... -- I done this to come to find out that in 6 months my insurance had put out almost $38,000 in re-imbursements... and they only paid $29,000 (and some change) for my girlfriends entire surgery.. including hospital and surgeon bills.. <br> There is a list of ICD 9 codes on one of the post-ops page (do a search here for ICD 9 codes, you're bound to find it) and look up the ICD-9 codes of all your co-morbids and potential co-morbids.. Of the family histories co-morbids.. <br> Have your PCP write a letter for you about the "quality of life and health care" you recieve and disfunctions morbid obesity causes you, to back up your claim.. <br> Take your medical chart and tear it apart... for every thing you've listed as a co-morbid cross reference it with facts in your medical chart.. make sure there's nothing in there you've forgotten.. if you've seen specialist, ob's, physical therapists.. ect.. don't forget those... <br> You quoted facts in your letter.. include where you got those facts.. from what experts.. <br> if you're "truely" consulting with an attourney, I'd have a name in there.. they get many "idle" threats of "my attourney said" make them believe it.. <br> Include pamphlets if you can find any that include the statistics on what morbid obesity can do to you, cross reference it in your letter <br> Include pamphlets of what Gastric Bypass can do for you.. again cross referencing it <br> Include pictures of yourself.. (bra and panties if you're not too modest) </p> I know this sounds like a lot of work, but I wish you luck.. It is worth every extra minute / hour/ day I put into fighting my insurance about it..
   — Elizabeth D.

February 12, 2002
Very, Very good !!! My wife and had to do two appeals and I don't think they were as well written as yours- and oh yea we also have BC/BS !!!!! I agree with the last post-send a picture,we did. Just keep your chin up, and keep fighting-it will work out. Ours did,it took 9 months but we finally got approved. In fact my surgery is in just a few hours-8am Wed. 2/12, and my wife's is 4/9 !!!!! Keep fighting and let us know what progess you make. God Bless !!!
   — gary B.

February 12, 2002
I think your letter had a lot of great points. The strongest point, in my opinion, was that it was going to cost your insurance a lot more money NOT to pay for the surgery, since your co-morbidities were going to be very expensive for them. Let us know how it turns out!
   — Terissa R.

February 12, 2002
First, let me say, that I reviewed your letter with my "medical reviewer"/"insurance specialist" hat on. I have over 20 years experience with health care insurers and in hospital finance. I have written appeal letters and I have received appeal letter. I can tell you put a lot of heart, soul and research into that letter. I can also tell you that the medical reviewer won't read half of your letter....not even a third of it. It's too long, it's disorganized, it'd strays from the facts of denial, it's threatening. The most effective way to piss of the medical reviewe is to mention your attorney in your opening statement. (lol). The most obvious suggestions are: 1. Skip all that stuff about ambiguous language in the contract. It's quite clear...they are excluded surgery for weight loss reasons. 2. Skip the Icd9 code for MO. It serves no purpose. 3. You want make it clear that the purpose of the surgery is not simply to lose weight. That your co-morbs (which are exacerbated) by the MO are the reasons for the surgery. List your co-morbids in the letter and include supporting documentation to that effect from your physician along with a statement from your physician that these conditons are caused by/exacerbated by your MO and that you have tried and failed to lose weight by medical and nutritional means. 3. Skip all the mortality rate stuff...you are dealing with professional people who know more about mortality and morbidity stats than you do. 4. Every statement that you allege to have been made by a physician should be supported by documentation from that physician. 5. Address co-morbids that you HAVE today! Medical reviwers can't make decisions based on what might befall you sometime in the future if you don't have wls. 6. Drop all the emotional stuff. Your health insurer doesn't care about your "feelings". They don't care about dress sizes, bathing suits and how society views fat people. All that extraneous stuff works against you anyway. If the reviewer is leaning toward approving you, she wants to see your strenghts...not your weaknesses. She wants to know that you have the strenghth and determination to comply with the dietary/fitness/lifestyle changes that wls requires for long term success. All that "pity the fat girl stuff" only serves to lead the reviewer to wonder if there's an emotional component that would undermine the effects of wls. Appeals letters should be clear, concise, unemotional and based on facts. Never threaten legal action or make accusatory statements. Save that for round 2, if your appeal is denied! (lol) The reviewer stands between you and your surgery. Don't piss her off! (lol).
   — [Anonymous]

February 13, 2002
Just to start off, I am in no way upset or mad at Anon's post as a medical reviewer, I just want to know why? So tell me, mister Anonomys medical reviewer, why not mention my attorney? They denied me the first time because of the exclusion in my contract! And because there is an exclusion, they will keep denying me, they dont care about facts! Why would it piss off a reviewer?? Wont it let them know that the statement is ambiguous? Wont it also inform them that by continously denying my surgery that they could possibly face a law suit? I was just wondering, since the denial letter to me stated clearly that they didnt even read all of the information that was sent to them, because as soon as soon as they got the info, They quited my the exclusion. And because I have an exclusion, will they even listen at all? I shall be sure to take out the emotional things, I certianly dont want anyone to feel sorry for me especially an insurance company who couldnt care a hill of beans if I popped off this world, it would save them money in the long run. I thank you all for your advice, and will make sure to let you all know how it comes out. :-D
   — Dina L.

February 13, 2002
I have to agree with the anon poster. The letter is WAY too long. Put yourself in the place of the reviewer. How many letters of that length would you/could you read on a daily basis. Also, if you want to invoke anything about an attorney, don't do it at the beginning. Again, put yourself in the reveiwer's place. If I walked up to you and said, I'm going to sue you if you don't agree with me, how likely would you be to listen? One more thing. When you do get this pared down, have someone go over it for grammer and clarity. I noticed the phrase 'to fuse the joint to elevate pain'. I believe you mean 'to fuse the joint to alleviate pain'. Good luck to you.
   — garw