Question:
Did I get denied or just asked for more information?

I need some help here. I got my letter from my insurance today, saying that based on that clinical information provided, medical necessity and/or appropriateness could not be determined, therefore they denied certification for admission. When I called them I talked to a person other than the nurse who made the determination. She read the notes and said that the denial was based on that fact that I had not included a psychologists review and that I had not included personal notes with regards to diets, weight history etc. Does this mean I have to go through an appeal, or do I just have to add those items to the claim, and that be it? Has anyone else gone through this? She said other than that she could not see notes stating that I did not qualify.    — stephanie Y. (posted on February 14, 2003)

February 14, 2003
I got a similar letter and like they told you it was only because the Psych Eval had not been completed. Once they had the Psych Eval, it was full steam ahead and I am happy to say I have a March 11th surgery date! So no you dont need an appeal, just provide the items requested.
   — Jenny B.

February 14, 2003
hi there, my cousin had gastric bypass about a month and a couple weeks after me, she had been denied the fitst time due to lack of information but as soon as the company got the info they needed, she was approved that day! :) best of luck to you! :)
   — carrie M.

February 15, 2003
The same thing happpened to me only I was calling the insurance co weekly to check on statis. The denied for the same, needing a psych eval, so my pcp got me in to one the next week, and the insurance company now has my psych eval and will have the final decision this week. Good luck
   — wizz46

February 15, 2003
Put the information together and then send it with a letter asking to have the request reviewed again. Don't call it an appeal. Save that in case you get a denial after they do have everything. It should not be a big deal for them to open it and review with the rest of info included.
   — zoedogcbr

February 16, 2003
They should have left your file open in a pended status and requested the additional information. I know doctors have different ways of doing things, but if this doctor has been doing this for any length of time his staff should know the basics of what insurance companies want. The surgeon I have won't even submit an incomplete package to insurance. It just holds the process up. Then again, perhaps your dr has not had that much experience in dealing with your ins co. Hopefully, he will learn from this and not let it happen again for future patients. In any event, not to excuse the dr himself, but generally he has a staff who should be familiar with insurance companies and their requirements. Good luck.
   — Diane S.

February 17, 2003
Christine, I would get the pysch evaul and diet information together. Send this information along with a copy of the letter they sent to you and a letter you write explaining that you are provideing information they requested. The insurance company should read the note in their system and take the info you supply and give you an final determination. I hope this helps.
   — Kevin D.

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