Question:
I got a letter of denial, What does this mean?
I got my letter from Anthem b/c b/s and it simply put stated that I was denied because there are no clinical findings to support my medical necessity for this surgery. Can you believe this???? Besides being 125lbs overweight i have high cholesterol, triglycerides, Acid reflux, patella femorol syndrome(my knees are not aligned right)so because of this I have early degeneration of the knees and arthritis.What was the number one thing my Orthopedic said I have to do??? You got it, LOOSE WEIGHT.I have constant leg pain and lower back pain.Am I not a good candidate for this surgery? I thought I was with just the weight itself! Any ideas? thanks Rebecca — REBECCA L. (posted on August 13, 2001)
August 12, 2001
IM REALLY SORRY. I KNOW HOW YOU MUST FEEL. I WAS TRUN DOWN FOR INSURANCE
AND YOUR WORLD JUST FEELS LIKE ITS FALLING PART. LET ME WISH YOU THE BEST
OF LUCK.
— [Anonymous]
August 12, 2001
You can appeal the denial! Try to get some more info on the denial. Make
sure you know exactly what it would take for your insurance company to
approve you. It may be they didn't get enough documentation. You could
get your other Doctors to write letters recommending you for the surgery
based on their medical findings. Go to the section on this site that
offers help getting insurance approval. Others before you have been denied
and appealed successfully, so it isn't out of the question. Please don't
give up.
— Susan M.
August 13, 2001
You should appeal. You need letters of medical necessity that
come right out and say you "must" lose weight to alleviate these
conditions, they can't just infer it. Then you have to document
that you have a history of unsuccessful attempts to lose weight by
medically supervised diets and/or through Weight Watchers, Jenny
Craig, etc. You really have to "connect the dots" for the
pre-approval people. Just being morbidly obese does not guarantee
automatic approval. The insurance reviewers are looking for co-morbidities
(..you have them), proof of unsuccessful attempts at weight loss, and
assurance that you can comply with the necessary lifestyle and nutrtional
changes that are crucial to weight loss after wls.
— [Anonymous]
August 13, 2001
What is your benefit? Do you have limitations or exclusions? The main
thing is you need to know their rules. What BMI do you have to meet and
what if any comorbidities do you have to have? I would get that and fight
the denial. Once you know the rules you will be better armed for the
fight.
— Dawn R.
August 13, 2001
Hi Rebecca, do you think you may have sleep apnea but have never been
tested, then I suggest you do so. This might help to overturn your denial
because it's considered a life threatening comorb along with HBP and
diabetes, and ins cos usually approve with proof. I was denied twice by my
ins co and was only approved after I'd had the sleep study and my
pulmonologist wrote a letter to the ins co recommending surgery. I do have
sleep apnea. Hope this helps, I wish you all the best.
— dandjon
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