Question:
Has anyone out there ever gone in front of a medical review board to plead thier case
If so, have you achieved positive results. I am asking this question for my sister whose greatest hope is approval for WLS. She has been denied twice, and now she has an option to go to the medical review board to plead her case. What should she say that will get thier attention (besides comorbs) and make them see that she is a REAL peron who needs this surgery? Thanks in advance yall. — Wendie G. (posted on November 25, 2003)
November 25, 2003
Hi Wendie,
I wish I had an answer for you. The only thing I can suggest is she get in
touch with one of the WLS attorneys. (www.obesitylaw.com or
www.obesitylawyer.com) In lieu of that, maybe self-paying... Hope she has
an excellent outcome!
Blessings,
dina
— Dina McBride
November 25, 2003
With Cigna it seems to be the only way people are being approved is on a
teleconference...we have a board on yahoo and it has been a real support
for many..
— jellyin
November 25, 2003
I have gone to the review board with BCBS for another issue but what I
found is that keeping emotions to a minimum is important. You hit them
with facts, how serious her co-morbs are and how they are affecting her
life and how much they are costing her insurance company. For me I went
from about $7000 a year in meds to $2000. I'm only on things for 2
disorders, but one is very expensive. So in 5 years times my surgery costs
will be paid for by my meds alone. Talk $ and Cents to them. Also, tell
her to look in her insurance booklet for their definition of medical
necessity. It should have 4 criteria. She needs to close her presentation
by address those criteria 1 at a time. How this surgery addresses those
issues.
<p>This is BCBS's definition of Medical Necessity and I think it's
the same with all insurances:
<p>MEDICALLY NECESSARY means a service, treatment, procedure,
equipment, drug, device or supply provided by a HOSPITAL, PHYSICIAN or
other health care provider that is required to identify or treat a
PARTICIPANT'S ILLNESS or INJURY and which is, as determined by BCBSUW:
<l>(a.) consistent with the symptom(s) or diagnosis and treatment of
the PARTICIPANT'S ILLNESS or INJURY;
<l>(b.) appropriate under the standards of acceptable medical
practice to treat that ILLNESS or INJURY;
<l>(c.) not solely for the convenience of the PARTICIPANT, PHYSICIAN,
HOSPITAL or other health care provider; and
<l>(d.) the most appropriate service, treatment, procedure,
equipment, drug, device or supply which can be safely provided to the
PARTICIPANT and accomplishes the desired end result in the most economical
manner.
<p>Address these and you might stand a chance. However, if it is a
clear written exclusion then nothing may change their decision. Showing
some emotion is fine but presenting a solid, well thought out arguement
will go further. I did this exact thing and the comment I got from the
lawyer and doctors on the board was that they had never seen a case that
well prepared and easy for them to figure out what I was trying to get
across. I had to provide them with office notes from 5 different doctor's
to get the big picture tied together, but I went through and summarized
what I wanted them to get out of that doctor's care and out of each note so
they did not have to read all the crap. All I know is it worked. So tell
her to give it her all as this is likely her last opportunity! Good Luck!
— zoedogcbr
November 26, 2003
Wendie ~ I sat on claim review committees for two different insurance
companies over a period of several years. The most successful appeals had
two consistent characteristics: the person knew what they were talking
about, and they came across across as a sincere jhuman being. They
understood their medical condition, and were able to talk about why they
needed the requested treatment, and specifically how it would help them
(similar to what Chris has already suggested). It will be very helpful if
your sister could talk a little bit about all of the other attempts she has
made at weight loss and maintenance to show that surgery is a last resort.
The second important element is to come across as likeable and deserving.
This has more to do with the personality your sister projects. She should
be sincere, coherent, and organized. She can be passionate, but not
overly-emotional. The more real and human she appears, the better for her.
To that end, do not read a prepared statement. Talk to the committee
members. It's OK to go off of notes, but make eye contact, and talk
instead of reading. It's OK if she's nervous, but she'll probably do
better if she practices a bit. Don't memorize a speech, but know the facts
and be comfortable talking about them. Don't be defensive or blaming, and
be prepared to answer questions. Have her do her homeowrk ahead of time.
Best wishes.
— Vespa R.
November 28, 2003
Hi Wendie...others here have already given you great advice. I just wanted
to add that I was denied twice and then was given the chance to be in on a
phone consult with the insurance committee. The letter said if I was
interested in participating, to call and confirm. When I called, the rep
told me they had given my file "one last look" and approved me
without going to the committee. I've heard this has happened to other
people too. Definately let them know she's interested in participating.
Maybe she'll luck out like I did. Smiles! Kimberly
— Kimberly S.
November 28, 2003
I have known several people who have done this but none of them had any
luck, especially if it is a place where you have MSC, premera, etc.....they
will not pay whatsoever!
It also all depends on if your policy prohibits it.
GOOD LUCK & I HOPE THEY ARE SYMPATHETIC!!
If not there is always self-pay.
— Saxbyd
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