Insurance Appeal Letter - Help please!

on 7/26/09 5:08 pm - Seattle, WA
RNY on 09/02/09 with
 I was denied on my initial application to BCBS of Illinois (which sounds like a common problem) becasue they say I didn't satisfy their requirement for 3 months of consistent weight loss attempts.  I did what my doctor told me to do (Weight Watchers / Low-carb) but that is not, apparently, good enough.  Whatever.  So my question is this:

Did you have to appeal?  Does anyone out there have a successful appeal letter in which I could use your format, or can you help point me to a place that does have this?  I know my surgeon and his insurance person will help, but I want to do whatever necessary to get this done right.

This is specifically for laparoscopic RNY, by the way.  Thank you!
"So, whether you eat or drink, or whatever you do, do all to the glory of God." [I Corinthians 10:31]

The name's Tami :)  Check out my blog and my twitter!

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Highest (2/09)Surgery (9/09) / Current  / High BMI / Current BMI
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on 7/26/09 8:39 pm - Wyoming County, NY

 HW 365/SW321                                                        Walk or Run 200 miles in 2010 

on 7/27/09 12:36 am - TX
I was denied twice by BCBS of Illinois.  I definitely think this is their tactic to deny in hopes that you will give up and go away.  Don't give up.  Fight.  It is worth it in the end.  I had to qualify under their old criteria of 6-mo diet + 5 yrs weight history proving morbid obesity.  Lucky you the change in their Medical Policy is now only a 3 month diet program and no weight history required.  You are welcome to read my blogs.  I would be glad to share my appeal letter with you if you feel the denial reasons are compatible.  My first denial was "not compliant with diet", not that I didn't follow a qualified program.  I appealed that and won but they came back with a 2nd denial stating I didn't have 5 yr weight history.  I won that too after finding an ER visit that just got me within that 5-yr timeframe.  Whew.  However, in your situation, I believe the Weigh****chers program is considered a qualified program as the Medical Policy says "like Jenny Craig, Nutrisystems, etc".  That's where you will need to start.  Your appeal should be focused only on the denial; your argument will be to counter it with examples of how it does comply with the criteria outlined on their Medical Policy.  That is what they have to base their decision to approve or deny upon.  It's on their website under Providers and then under the Library section there is a link to Medical Policies.  Click the "I Agree" button and then go to page 17, Surgery for Morbid Obesity.   Review your WW diet and make sure your diet program provided the items outlined there.  If not, then the WW diet program does not meet their criteria of a comprehensive non-surgical weight loss program.  If it did then you may only need to send in proof with copies of the weigh-ins, counseling notes, etc.  

I finally got my surgery but there were times when I thought I would lose my mind from frustration.  Calling them was a real joke too because each time you'd hear something different and usually incorrect.  I don't know where they get their customer service reps from.  I still have an un-reimbursed claim for my psyche evaluation because BCBS and the psyche doc never agreed on how it was to be filed / paid.  So guess who got to pay $245 out of pocket for a supposedly in-network doctor?  Anyway, PM me if I can help further.  I'm not an insurance expert or lawyer but I went down a rocky road with BCBS/IL and I feel better each time I'm able to help someone overcome their BS.  -----  Pat
on 7/27/09 1:41 am - Simi Valley, CA
I was denied three times in four years by BCBS of Illinois.

The information/reference below is something I wrote for the benefit of another poster on here -- although I sent to her privately -- and tells about my experience, and what I did. I gave the Obesity Law & Advocacy Center a call.

The phone number is (619) 656-5251. Ask for Kelley Lindstrom.

Below is the reference letter and information about my experience that I wrote to another poster, with some appropriate slight editing done for purposes of privacy and updating.


I wanted to get in touch with you in order to give you a reference that I was told you requested regarding the Obesity Law & Advocacy Center.

The Chula Vista-based company is a leader in helping clients resolve legal issues related to medical treatment of and discrimination against people suffering from obesity and its related problems.

After my experience with the firm, I can certainly see why.

When I first contacted Walter and Kelley Lindstrom, it was after I had been denied insurance coverage of RNY gastric-bypass surgery twice in three previous years. At the time, I also was in the midst of another fight for the WLS operation, trying again with a third, different surgeon/doctor's office.

This was happening despite my doing more in terms of preparations, documented doctor visits, problems, a six-month, supervised and documented weight-loss plan, a 5-year history of personal weight-loss efforts, etc., than most patients ever do, or are ever required to do, by their insurance companies. (I had Blue Cross/Blue Shield of Illinois).

After receiving a second denial of my third attempt to have surgery, my surgeon -- the one who finally performed the operation -- suggested I contact the Obesity Law & Advocacy Center and, with their help, make an appeal of my latest denial.

I have to say, the Obesity Law & Advocacy Center came through for me very quickly, and in a big way, to say the least.

BC/BS of Illinois is well-known for presenting moving targets, with their requirements and responses and reactions to you changing as needed from their point of view on the basis of your latest responses/requests/information.

This is how they (and other insurance companies) get people to finally just give up and go away. DON'T do it. That's what they want.

I didn't have to, because, a little more than three weeks after the Obesity Law & Advocacy Center sent in an appeal of BC/BS of Illinois's denial on my behalf in late June/early July of 2008, I received a letter of approval of my surgery from the insurance company. 

I underwent a gastric bypass operation on Aug. 6, 2008, and have done well in recovery since then. I probably would never have gotten to this point if it had not been for the help of the Obesity Law & Advocacy Center.

The Lindstroms' office does not accept everyone's case, instead taking only those they believe they have a good chance to win, preferably through the appeal process and before the case ever actually goes to court.

So, if you've contacted them, and they've told you that they feel you have a good case, I'd recommend that you go ahead with the process, because they usually win!

I also found their rates to be surprisingly reasonable, and, if they tell you they think they can help, any money spent will be well worth it.

It certainly was for me. I paid a one-time fee, which covered everything, and I just put it on my credit card, although I believe they also have an installment option if you need/prefer that.

After that, the OLAC helped me so quickly and so relatively easily that I only wished I'd gotten in touch with them months, and even years, before I was.

It took about two weeks, all told, from the time of my initial consultation, through their gathering/my sending all appropriate information, to them sending me a copy of the appeal "letter" (actually it was an impressive and intimidating 18-page document written up by Walter Lindstrom that I NEVER could've or would've written myself) that they sent to the insurance company on my behalf.

If I remember correctly, it took another week to 10 days or so to hear back from the insurance company that my surgery had been approved. So, all told, it took about three weeks, or maybe, just under four, to get approval, once they took over.

The OLAC tries to make the process accessible, financially, by handling it before it gets to the level of a real, actual court case -- although they would probably do that, too, if needed, once they've committed to your case.

I don't know that, for sure, because they won my case through the appeal process and we never had to go that far. But, when the OLAC has committed to you, it will also be there and available at your disposal post-approval and post-surgery, should there be any further need for that -- like, say, if the insurance balks, either to your surgeon's office or to you, once it actually receives the hospital and/or surgeon's bills and it comes time to actually pay up.

(I'm having this issue right now, and we're waiting to see what happens. But Walter has assured me that he will step in and help again should that be needed).

Anyway, going to the Obesity Law & Advocacy Center for help was an extreme extra step that I felt I had to take in order to try to finally get approval of my weight-loss surgery, and it worked -- more easily than I imagined it would.

It guess it really is amazing what hiring a lawyer can do.

For me, there were no problems and no hassles, and, after having been denied surgery by my insurance company three times in a four-years span, it was well worth the money.

And, after trying for this for so long, anyway, another month's wait was nothing. It went by fast, and, best of all, I was amazingly at-ease throughout, just because I knew I had someone else in my corner who was taking care of it all.

And they did.

Feel free to PM me if you'd like to ask anything else or discuss things further. I'd be happy to talk to you.

Good luck!

I hope this helps you and might be an option. I'd give this a try if you're frustrated enough or don't feel like you can, or want to, handle things yourself.

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