Question:
I am a pre-op with a question about.....
insurance appeal letter. I have to write an appeal letter to my insurance company. Anyone have any advise on the best way to phrase things for an approval. I was denied the first time because I had to do the 6 month supervised diet. I am now finished with that and need help with an appeal letter to bc/bs of Al. Thank you for all your help and suggestions. Tracy — Tracy LeAnn (posted on September 7, 2006)
September 7, 2006
Hi!
I too have BCBS and am preop. May I ask why you were denied?
Good Luck in your journey.
Donna WV
— K&BradsMom
September 7, 2006
Tracy, have you made sure you have met all the criteria your insurer
requires? If you aren't sure you know all the criteria, call the insurance
precertification department or customer service and ask them to fax or mail
you a copy of the written criteria. If you are sure you have met all the
requirements, then you only need to say HOW you meet criteria - every one
of them, not just the 6 month supervised diet.. Avoid being emotional in
the letter. State facts. Send me an email and I can fax you a copy of a
couple of appeal letters I wrote.
— koogy
September 7, 2006
I was denied because I hadn't done the 6 month supervised diet and because
my insurance says I have to have a BMI of 40 or higher for at least 3 years
and mine had went down under 40 in 2004.So I am now in the process of
appealling their decision.
— Tracy LeAnn
September 7, 2006
Tracy, What insurance do you have? Cigna? What was the denial? I just
went through the same thing.
— robyninthehood
September 7, 2006
Tracy, because you said your BMI went below 40 two years ago, I would make
a point in your letter to state that it obviously came back up because you
were unable to keep it below 40, despite your best efforts.
— koogy
September 7, 2006
My Appeal Letter
February 15, 1999
Dear Review Committee:
This letter comes in response to my recent denial for surgery. I am writing
this letter to appeal your
decision. I will use this forum to tell you about myself and my history as
well as educate you in the
arena of Weight Loss Surgery.
I am a 36 year old morbidly obese wife and mother of three children. It is
my dream to be able to go on bike rides, hikes, walks, even amusement park
rides with my kids. Things the "normal" person takes for granted.
When I walk from my car to my office, my heart is pounding and racing. I am
so out of breath
people stare. My lower back is so painful, I can not walk for long periods,
I have to stop and rest for a bit.
I suffer from severe acid reflux disease, incontinence, severe chronic
lower back pain, and depression. It has been documented that all of these
problems can be helped, if not cured, by losing weight. I have tried many,
many diets. (I have included my diet history with this letter.) The most
weight I was able to lose was 30 pounds. My BMI is 44, that makes gastric
bypass surgery a medical necessity.
I am very well educated in the area of Gastric Bypass Surgery. I have been
researching for months. I have been going to support group meetings where
the participants are mostly post operative gastric bypass surgery patients.
I also belong to a support group mailing list of over 600 members, both
post-op and pre-op. I have learned a tremendous amount from all these
people. I know what this surgery is and what it will do for me and my life.
That is why I want and need to have this surgery. And after reviewing my
family medical history, you will probably agree with me that to not have
this surgery will surely lead to more severe medical problems in the
future.
Here is my family medical history:
Grandmother on my mother's side died of a massive heart attack at age of
42. One of my mother's brothers died of a massive heart attack while
waterskiing at age 32. Another of my mother's brother's had a triple bypass
at age 37. My mother has coronary vascular disease. My Grandmother on my
father's side had diabetes, and died of heart failure at age 67. Obesity
runs on both sides of my family.
My PCP, my surgeon, and my Psychologist all agree that this procedure is
the right option for me. I also agree with them. I want this surgery. It
will save my life, and give me back what life I have left. I will not give
up on getting this procedure approved. I will keep coming back. However, if
this surgery request is denied a second time, I will not be coming back
alone. I have already spoken with an attorney, who will be representing me
if the need be. So, I beg you, please approve this surgery... I will not go
away.
There has been a lot of misconception about this surgery, so I have take
the liberty of going to the American Society for Bariatric Surgery (ASBS)
website and gathered this information for you.
Clinically severe (Morbid) obesity correlates with a Body Mass Index (BMI)
of 40 kg/m2 (or higher) or with being 100 pounds overweight. Being
overweight is associated with real physical problems which are now well
recognized. The most obvious is an increased mortality rate directly
related to weight increase.
Obesity is dangerous to health because of the associated increased
prevalence of cardiovascular risk factors such as hypertension, diabetes
mellitus, hypertriglyceridemia, hyperinsulinemia and low levels of high
density lipoprotein (HDL)cholesterol. Cardiovascular risk factors are
reduced significantly by sustained weight reduction. Data from the
Framingham study support the estimate that a ten percent reduction in body
weight corresponds to a twenty percent reduction in the risk of developing
coronary heart disease.
The risk for diabetes has been reported to be about twofold in the mildly
obese, fivefold in moderately obese and tenfold in severely obese persons.
The risk of developing diabetes also increases with age, if a family
history is present and if the obesity is central.
Surgical treatment is medically necessary because it is the only proven
method of achieving long term weight control for the severely obese.
Surgical treatment is not a cosmetic procedure. Surgical treatment of
severe obesity does not involve the removal of adipose tissue (fat) by
suction or excision. Bariatric surgery involves reducing the size of the
gastric reservoir, with or without a degree of associated malabsorption.
Eating behavior improves dramatically. This reduces caloric intake and
ensures that the
patient practices behavior modification by eating small amounts slowly, and
chews each mouthful well. Success of surgical treatment must begin with
realistic goals and progress through the best possible use of well designed
and tested operations. These have been worked out over the last thirty
years, and are now standardized, clearly defined procedures, with well
recognized and documented outcome results.
Prevention of secondary complications of severe obesity is an important
goal of management. Therefore, the option of surgical treatment is a
rational one supported by the time honored principle that diseases that
harm call for therapeutic intervention that is less harmful than the
disease being treated.
The option of surgical treatment should be offered to patients who are
severely obese, well informed, motivated, and acceptable operative risks.
The patient should be able to participate in treatment and long term
follow-up. A decision to elect surgical treatment requires an assessment of
the risk and benefit in each case. Increased abdominal fat or "central
obesity" (apple shaped as opposed to pear shaped) is an important risk
factor associated with the major complications of obesity.
Patients whose BMI exceeds 40 are potential candidates for surgery if they
strongly desire substantial weight loss, because obesity severely impairs
the quality of their lives. They must clearly and realistically understand
how their lives may change after operation.
Weight reduction surgery has been reported to improve several comorbid
conditions such as glucose intolerance and frank diabetes mellitus, sleep
apnea and obesity associated hypoventilation, hypertension, and serum lipid
abnormalities. A recent study showed that Type II diabetics treated
medically had a
mortality rate three times that of a comparable group who underwent gastric
bypass surgery. Also preliminary data indicate improved heart function with
decreased ventricular wall thickness and decreased chamber size with
sustained weight loss. Other benefits observed in some patients after
surgical treatment include improved mobility and stamina. Many patients
note a better mood, self esteem, interpersonal effectiveness, and an
enhanced quality of life. They have lessened self consciousness. They are
able to explore social and vocational activities formerly inaccessible to
them. Self body image disparagement decreases. Marital satisfaction
increases, but only if a measure of satisfaction existed
before surgery. If marital discord exists preoperatively, the improved self
image may lead to divorce postoperatively.
I appreciate your attention to this appeal. If you have any questions or
need any further documentation, please call me.
Sincerely,
Debbie - Pre-Op
This was taken in August 1998
Debbie - 7 wks Post Op
Down 40 pounds 6/7/99
Debbie - 10 wks Post Op
(with my husband, Tom) Down 50 pounds 6/27/99
Get Notified When I Update My Journal!
Click here:
Click on Pic to email me!
My Appeal Letter
February 15, 1999
Dear Review Committee:
This letter comes in response to my recent denial for surgery. I am writing
this letter to appeal your
decision. I will use this forum to tell you about myself and my history as
well as educate you in the
arena of Weight Loss Surgery.
I am a 36 year old morbidly obese wife and mother of three children. It is
my dream to be able to go on bike rides, hikes, walks, even amusement park
rides with my kids. Things the "normal" person takes for granted.
When I walk from my car to my office, my heart is pounding and racing. I am
so out of breath
people stare. My lower back is so painful, I can not walk for long periods,
I have to stop and rest for a bit.
I suffer from severe acid reflux disease, incontinence, severe chronic
lower back pain, and depression. It has been documented that all of these
problems can be helped, if not cured, by losing weight. I have tried many,
many diets. (I have included my diet history with this letter.) The most
weight I was able to lose was 30 pounds. My BMI is 44, that makes gastric
bypass surgery a medical necessity.
I am very well educated in the area of Gastric Bypass Surgery. I have been
researching for months. I have been going to support group meetings where
the participants are mostly post operative gastric bypass surgery patients.
I also belong to a support group mailing list of over 600 members, both
post-op and pre-op. I have learned a tremendous amount from all these
people. I know what this surgery is and what it will do for me and my life.
That is why I want and need to have this surgery. And after reviewing my
family medical history, you will probably agree with me that to not have
this surgery will surely lead to more severe medical problems in the
future.
Here is my family medical history:
Grandmother on my mother's side died of a massive heart attack at age of
42. One of my mother's brothers died of a massive heart attack while
waterskiing at age 32. Another of my mother's brother's had a triple bypass
at age 37. My mother has coronary vascular disease. My Grandmother on my
father's side had diabetes, and died of heart failure at age 67. Obesity
runs on both sides of my family.
My PCP, my surgeon, and my Psychologist all agree that this procedure is
the right option for me. I also agree with them. I want this surgery. It
will save my life, and give me back what life I have left. I will not give
up on getting this procedure approved. I will keep coming back. However, if
this surgery request is denied a second time, I will not be coming back
alone. I have already spoken with an attorney, who will be representing me
if the need be. So, I beg you, please approve this surgery... I will not go
away.
There has been a lot of misconception about this surgery, so I have take
the liberty of going to the American Society for Bariatric Surgery (ASBS)
website and gathered this information for you.
Clinically severe (Morbid) obesity correlates with a Body Mass Index (BMI)
of 40 kg/m2 (or higher) or with being 100 pounds overweight. Being
overweight is associated with real physical problems which are now well
recognized. The most obvious is an increased mortality rate directly
related to weight increase.
Obesity is dangerous to health because of the associated increased
prevalence of cardiovascular risk factors such as hypertension, diabetes
mellitus, hypertriglyceridemia, hyperinsulinemia and low levels of high
density lipoprotein (HDL)cholesterol. Cardiovascular risk factors are
reduced significantly by sustained weight reduction. Data from the
Framingham study support the estimate that a ten percent reduction in body
weight corresponds to a twenty percent reduction in the risk of developing
coronary heart disease.
The risk for diabetes has been reported to be about twofold in the mildly
obese, fivefold in moderately obese and tenfold in severely obese persons.
The risk of developing diabetes also increases with age, if a family
history is present and if the obesity is central.
Surgical treatment is medically necessary because it is the only proven
method of achieving long term weight control for the severely obese.
Surgical treatment is not a cosmetic procedure. Surgical treatment of
severe obesity does not involve the removal of adipose tissue (fat) by
suction or excision. Bariatric surgery involves reducing the size of the
gastric reservoir, with or without a degree of associated malabsorption.
Eating behavior improves dramatically. This reduces caloric intake and
ensures that the
patient practices behavior modification by eating small amounts slowly, and
chews each mouthful well. Success of surgical treatment must begin with
realistic goals and progress through the best possible use of well designed
and tested operations. These have been worked out over the last thirty
years, and are now standardized, clearly defined procedures, with well
recognized and documented outcome results.
Prevention of secondary complications of severe obesity is an important
goal of management. Therefore, the option of surgical treatment is a
rational one supported by the time honored principle that diseases that
harm call for therapeutic intervention that is less harmful than the
disease being treated.
The option of surgical treatment should be offered to patients who are
severely obese, well informed, motivated, and acceptable operative risks.
The patient should be able to participate in treatment and long term
follow-up. A decision to elect surgical treatment requires an assessment of
the risk and benefit in each case. Increased abdominal fat or "central
obesity" (apple shaped as opposed to pear shaped) is an important risk
factor associated with the major complications of obesity.
Patients whose BMI exceeds 40 are potential candidates for surgery if they
strongly desire substantial weight loss, because obesity severely impairs
the quality of their lives. They must clearly and realistically understand
how their lives may change after operation.
Weight reduction surgery has been reported to improve several comorbid
conditions such as glucose intolerance and frank diabetes mellitus, sleep
apnea and obesity associated hypoventilation, hypertension, and serum lipid
abnormalities. A recent study showed that Type II diabetics treated
medically had a
mortality rate three times that of a comparable group who underwent gastric
bypass surgery. Also preliminary data indicate improved heart function with
decreased ventricular wall thickness and decreased chamber size with
sustained weight loss. Other benefits observed in some patients after
surgical treatment include improved mobility and stamina. Many patients
note a better mood, self esteem, interpersonal effectiveness, and an
enhanced quality of life. They have lessened self consciousness. They are
able to explore social and vocational activities formerly inaccessible to
them. Self body image disparagement decreases. Marital satisfaction
increases, but only if a measure of satisfaction existed
before surgery. If marital discord exists preoperatively, the improved self
image may lead to divorce postoperatively.
I appreciate your attention to this appeal. If you have any questions or
need any further documentation, please call me.
Sincerely,
Debbie - Pre-Op
This was taken in August 1998
Debbie - 7 wks Post Op
Down 40 pounds 6/7/99
Debbie - 10 wks Post Op
(with my husband, Tom) Down 50 pounds 6/27/99
Get Notified When I Update My Journal!
Click here:
Click on Pic to email me!
Try this link. You'll have to copy and paste.
www.obesityhelp.com/morbidobesity/information/wlsjourney/insurance+trouble.php
-
— MamaPea
September 7, 2006
Tracy,
I have BCBS of Pa. I am two months post op. I was also denied because of
the 6 month visits. My doctor just resubmitted after the 6 months were up.
He included the office notes along with the original material and i was
approved in a matter of a week.
Good luck
Camille C.
— camille1956
September 7, 2006
Tracy I also had to appeal to my insurance. I have bc/bs-trs. After I
appealed and they got all the paper work back in I was approved in about
two weeks. If you would like a copy of my letter I would be glad to send it
to you. Let me know and good luck.
Laural
— Laural D.
September 7, 2006
I have some that have been passed along. There are also some helpful links
I came across. Email me so I can send them directly to you.
[email protected]
Sha
— Shaniece H.
September 7, 2006
You can also click on Insurance and scroll down to Appeal Help and OH shows
you an example letter too!
Sha
— Shaniece H.
September 8, 2006
Go to your search engine, try more than one. Enter appeal letter for weight
loss surgery or how to write an insurance appeal letter. It will give you a
good letter to go by, where you can substitute your name and conditions.
That's what I did.
— geneswife
September 8, 2006
my primary physician wrote the appeal letter foer me. maybe yours can as
well. good luck!!!
— shannonwaycott
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