Question:
Insurance carrier Rejected request from surgeon. Help
My carrier is United Healthcare Options. BMI is under 40 reason for rejection. Was told to retain a lawyer and need to write letter for appeal. Need some direction. What type of lawyer and how to address the rejection. Do I go after the BMI issue? — Bradys_mom (posted on August 12, 2009)
August 12, 2009
What is your BMI if you don't mind me asking? I think you can appeal your
insurance decision without a lawyer. Do you have any heath issues due to
your weight?
— Supersize
August 12, 2009
Most Insurances cover if BMI is 40 or more OR more then 35 with risk
factors..... if you have any risk factors like sleep apnea, high blood
pressure etc. then you can send letters from your doctors who treat you for
those... I would get letters from all doctors stating the benefits of wls
to your insurance carrier.. don't give up yet and I wouldn't hire a lawyer
just yet. Usually your surgeons office will know the requirements of your
insurance and be able to instruct you on how to proceed.. Good Luck!!!
— wendy-s
August 12, 2009
Don't give up just yet and get an attorney. If you have any co-morbidities
like acid reflux, sleep apnea, diabetes, high blood pressure; all of these
are considered life threatening. So if your doctor can deem your surgery
medically necessary, then you should get approved. My BMI was 39 and I had
comorbidities. All insurance companies have an exclusion which states they
exclude weight loss programs or surgery (unless deemed medically
necessary). So have your doctor resubmit the papers and keep filing
appeals, your surgeon should be doing all the dirty work for you. Hope it
turns out okay for you. What are your life threatening issues are the
questions you can ask yourself and then go over it with your doctor. Not
your PCP, but the Bariatric surgeon.
— Kristy
August 12, 2009
You don't need to hire a lawyer. Same thing happened to me and I wrote
them a letter stating my history, my co-morbidities, my struggle for years
with obesity and my plea for the surgery with a written commitment to
follow directions and accept that this is a lifestyle change, not a magic
bullet. I was sincere, telling that my whole life was a struggle because
of my weight. I learned from another LapBand patient to also write my
experience with "fat prejudice" and how my weight had cut me off
from enjoying and participating in life. I wrote it out in long-hand and
directed it to my case manager at Aetna Ins. I got a call from my Dr.s
office about a week later that they had approved my surgery.
I know from experience that writing the letter in long-hand was significant
as far as the insurance goes. They get phone calls, emails, even meet f2f
at times, but the physical letter in their hands actually give them cause
to re-evaluate your situation. Because there is a letter, they give it
more time and thought than a 10 min phone call.
Good Luck. I'm 9 months post op and I'm down 100#. I even took a picture
and sent it my case worker with a thank you when I reached the 100# mark.
— BeenThere1
August 12, 2009
I also have UHC and was denied for the surgery. I have recently filed an
appeal and am waiting to hear something, hopefully by September 10. My
original surgery date was set for Septemer 8. Don't fear the insurance
company, that is what they want is for you to give up and accept their
decission.
UHC told me it was not a treatment decission and that treatment decissions
are made between a doctor and the patient. If they will not cover life
saving surgery aren't they making a treatment decission?
Think about it.
Follow the other peoples advise that have posted here and appeal,
appeal,appeal.
Even though I have not heard anything and just begining the appeals process
I have started working on a second appeal because my health status has
changed and I want to be prepared to make a plea for them to save my life.
With out the surgery I am most likely to have a major stroke with in the
next 6 months to a year as my dr just diagnosed me with already having 2
mini strokes in the last 6 months.
Good luck and take care and keep fighting
Zells_lori
— abuddingrose
August 12, 2009
I,too, was rejected. The best thing you can do is get the patient advocate
in your doctor's office and do an appeal. Have the doctor write a letter
of necessity and explain the need for the operation such as bmi,
co-morbidities, and how it's affecting. The only reason I'm saying this is
because I'm currently doing the exact same thing. If I'm rejected again,
then I might need a lawyer to help me fight.
— Kathleen W.
August 13, 2009
No you shouldn't need a lawyer, but if you are going to spend money on one,
do it through www.obesityhelp.com, I think the guys name is Lindstrom,
(approx $600) you won't get denied after he deals with it. But you
shouldn't have to go that far if you appeal it with your
comorbidities..high blood pressure, high cholesterol, sleep apnea, liver
tests showing abnormal levels, GERD, arthritis, diabetes, etc, are examples
— eyeflirt4fun
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