I got denial for consultation! please help!

Hi all, I am desperately in need of some help. I have Covered California HMO plan and there is no Bariatic specialist in my group. My primary MD tried to refer me to a outside Bariatric surgeon for consultation which has been denial by my insurance, stating "obesity treatment of any kind is not a covered benefit based on my evidence of coverage. However, I found in my EOC booklet that obesity treatment is not covered (unless medically necessary). I want to appeal but I just don't know where to start. I am hypertensive, pre-diabetic, have high cholesterol and my BMI is 37.6. Please advise. Thank you very much!

Call your insurance company and ask what their formal appeals process is.

I believe your hypertension is considered a co-morbidity, but not sure if high cholesterol or pre-diabetes qualify (you may have to prove full diabetes).

Most insurances who cover WLS will approve with a BMI of 40/no co-morbidities or BMI of 35 with 2 co-morbidities.

So,with your current BMI, you may have an uphill battle, but still it is worth researching your options and beginning to document everything for an appeal.

Good luck.

That's going to be a tough one.  You'll need your doc on your side to advocate and play up your comorbities.

Your BMI is under 40 so as mentioned by a previous person you have to have 2 co-morbidities I know Hypertension is 1. and 2. high cholesterol or dyslipidemia counts as another also included are Gastroesophgeal Reflux, Urinary Incontinence ,Degenerative Disc Disease, Osteparthritis, Family History heart disease, heart attack and stroke, Sleep Apnea, Depression, Polycystic Ovarian Syndrome, and more. I agree with other members though, you will need your Doctor on your side to help you appeal, fight and play up your co-morbidities, I'm sure if your doctor does some testing he can come up with enough co-morbidities that the insurance company can't honestly dispute it.. Also I know on this website under resources they have an article on Medical Necessity take the time to read it and maybe it will help you Good-Luck if this is what you truly what then fight for it and don't give up :-)

I just had rny 7/22, my BMI was about the same as yours.  I have high cholesterol and high blood pressure.  Both are considered a co-morbity.  Good luck!

I would bet that they don't cover it at all (maybe your booklet is out of date) even with medical necessity any more. Since they don't have a bariatric surgeon in your group there is a good chance they don't cover it. Many insurance groups no longer cover surgery because it is so expensive. It can't hurt to try to appeal but don't be surprised to find it is no longer a covered item.

Does anyone have suggestion as to how a strong appeal letter should look like? Thank you.