Appeal letter

So my doctor told me that even thou my insurance policy doesn't cover BARIATRIC SURGERY she would like to write a letter of Appeal that states it's necessary that I have this surgery. Has anyone been through this and what was the outcome??

 

I haven't, but I know a thing or two about insurance :)

Basically things that are not covered can become covered.  If he submits an appeal, it has to be reviewed.  The plan medical director can then change the rules, override the benefit plan in your favor.  It happens rarely, but it happens.  If the case can be reasonably made that the surgery is not only medically appropriate, but is also a projected net cost reduction and risk improvement, then you may get the benefit of the doubt. 

Depending on your policy though, there is another possibility.  Some policies have a denial arbitration rule.  A great example is Medicare- if you're denied something on some Medicare plans, it is automatically appealed.  Then it can be further appealed to an Administrative Law Judge, who can override any clause in your policy and any decision the ins company makes. Some non-government plans also will have these types or provisions. 

Finally, following all of these rules can also give you the ability to say "Look, I followed all the rules, I did what I could, I need this anyway" and then go public.  Ins companies hate that kind of publicity. 

Thank you so  much. I had no idea that I'd have to jump through hoops to get this surgery covered. Ugh

To build on what Michael said - I had to appeal all the way to my husband's company's medical director to get approved. They denied me because I was underfat/overtall. Not only was I eventually approved, but the company directed UHC to change the criteria necessary to qualify for surgery. It was a HUGE win.

I hired Walter Lindstrom's office to help me with my appeal, and I'd recommend you reach out to them for info/insight even if you don't hire them. They are wonderful and will spend time talking through your options. Some nuggets of what I learned going through this -

Even if the surgery is specifically excluded on your insurance, there is a possibility that you could appeal and get it covered. The way it worked last year (before some of the new Obamacare stuff kicked in this year on 1/1) is that if your plan was structured in a certain way, if you went all the way to the independent review stage, your case would be evaluated on the medical necessity, i.e. based on a bariatric surgeon's medical opinion, not a beancounter's. You could win based on this and the insurance company would be obligated to pay. The new rules on 1/1, from what I understood, would only make it easier to fight and win.

There are plenty of hoops and protocols and dates to jump through in order to be successful at this. It isn't easy - frankly the period of time (5 months) I was in appeal status were some of the darkest days of my life. BUT, the output was so worth the effort. Be brave, and fight for it. Consider calling Kelley Lindstrom, Walter's wife, and talk through your questions with her.

Best of luck to you -
Laurie

Laurie,

 

Thank you for such great information. I have a question. When I called my insurance and they told me that I can appeal it they didn't tell me what to do. So my question is what's next. Do I just go to my doctors office and let them know they need to write an appeal letter? My doctor said she would if she needed to because my BMI is over 60 and have losts of co-morbidities. Can you tell me what i need to do?

you either need a document called an "Evidence of Coverage"- a book that describes all of the appeal rules, and pretty much all parts of your policy, or you need to spend alot of time researching this on the company's website.  Tey have to tell you how to appeal.  they don't have to make it easy. Most don't. 

At the very least you need to write a letter, have all of the details, etc.  You need to start a notebook. Everytime you talk about this with someone either with your employer, your doc, or your ins co, document it.  Names, times, dates, discussions, important phrases.  This will help you later.

Finally, don't get emotional.  The first person to get emotional loses.  Just be objective, factual, professional, and help them make the case that it's both medically necessary and financially wise to do this.  This is why a support person like a lawyer can help. 

Thank you Michael, when i called the insurance company all they did was direct me to the companies website to look for the medical policy for Bariatric Surgery and told me I needed to contact my PCP (who told me once before she'd be happy to write a letter of appeal). They also gave me the fax number to send the letter to. She didn't say I needed to do anything else than that. So my next step was to make my dr's appointment and let her know what they have told me.

I have already gotten emotional once when i found out it wasn't covered and I just gave up. Today something made me call the benefits department and ask again what i can do.

You're on the right track.  Just keep pushing.  You can be successful.  Do your homework, read the sites, look for the rules.  When I went in I had the medical policy in my hands and I already had evidence that I'd met the criteria.  Use their rules in your favor. Remember, at  the end of the day you have a tactical advantage.  You have time, tenacity, and patience on your side.  Become a big enough bother and they'll give in just to shut you up.  :) 

Thank you for the encouragement :-)