Question:
2nd level appeal...medical committee???

I just got a letter from my insurance company about my 2nd level appeal. It says a committee that includes a medical director and some other people will get together in September to review my appeal. It also says I can be present or be in on a conference call if I want. Or, I can have my surgeon or other representative be at the meeting or call. I'd like to know if anyone else has ever been thru this and did you attend? I don't have to, but I wonder if it will help. I'd love to hear from anyone whose been to one and knows what happens during the meeting...K    — Kimberly S. (posted on August 26, 2003)

August 26, 2003
Are you on yahoo cignassqueakywheels? some there have gone through this...we are all cigna losers..LOL
   — jellyin

August 26, 2003
Kimberly, Yes I just had a conference call last Tuesday on my second level appeal I have cigna ppo...I had 10 minutes to plead my case..I also asked them if I could have the gal from my dr.'s office on with me and they said sure. As my doctor was not in at that time...I just went step by step that I had all the info they wanted..I was only asked two questions..and the gal fom my dr's office was a great help and added in her two cents worth for me...that helped...well when it was done I was told I would hear something in 5 business days...we hung up/then 3 minutes later cigna called me back and said I did a great job and approved me!!!!! I hope this helps you....Karen
   — Karen D.

August 26, 2003
I used to sit on two of these claim review committees, for two different insurance companies. While we tried to be as objective and fair as possible to all who came before us, I must admit that those who came to the hearing in person were more likely to get a yes than those who attended by phone than those who simply sent a written plea. It's just human nature--the members of the review committee connect with you better on a human level if they see you and meet you. It's easier to empathize with someone's issues, and harder to say "no" when you've looked them in the eye. I strongly recommend attending in person, if at all possible. That may be too much to ask of your doctor, but if you could get someone from his office on a conference call, that would also help. In your few minutes to talk to the committee, be calm and knowledgeable. Present your case with facts and figures. Quote the NIH criteria for considereatin of WLS, and explain how you meet or exceed every one of the criteria. Talk about your co-morbidities, the treatments you're currently under, and how these conditions will only worsen if your obesity problem is not permanently resolved. Tell them about all of the other attempts you have made to control your weight. Be reasonable, but passionate. Have your facts at hand. Avoid the temptation to simply read a prepared statement. You are much more human if you TALK to them (use notes to keep you on track and get your facts correct, but don't read). My best wishes to you for success.
   — Vespa R.

August 26, 2003
Go in person!!!!! I spent 3 years in claim appeal with BC/BS over chiropractic claims. The first two appeals were just ignored and the reviewer truly refused to see the big picture. There were many medical issues going on at the time. My final appeal went to the Department of Employee Trust Funds, in other words my employers appeal level. They did an initial review and pretty much agreed with BC/BS but never put it in writing. There was another level of appeal above them and they did their best to talk me out of it. At first I gave in and then I got ticked and called back and said no. I wanted my day in court so to speak. <p>Well what happened is that this department made BC/BS go back and do a 3rd claim appeal in great detail and this time I was allowed to attend the claim appeal meeting. I had been denied before and told because I was a State employee that I could not attend, which was bogus. I put together a detailed, very organized summary of all medical conditions and how they factored in. I had doctor's notes with the pertinent things highlighted so they knew what to read. I also did a summery that overlapped the chiro treatments with other treatments etc. The end result was I won and every last claim was paid. The lawyer on the board said he was very impressed with how everything was organized etc. As I went through the big picture and tied all of the medical conditions together the doctor on the board just kept shaking his head yes that what I was saying was all medically correct and logical. <p>You have nothing to lose and everything to gain by taking the time to go. See you face-to-face and the size you are and difficulties you have cannot hurt. You need to make sure you focus on why you were denied and relate it to the 4 definitions of medical necessity. Address them one at a time and why you feel that the surgery is appropriate based on that criteria. Also provide some info from the NIH that indicates what BMI's and co-morbs qualify you for surgery etc. Get to the point but be thorough. Put together a summary sheet you can leave with them. You can address the personal side of the situation but the bottom line is you need to convince them you meet the requirements of medical necessity, end of story. If your surgeon's or PCP's letter were not very strong and clearly pointed out the medical necessity side of things ask them to write another letter and specifically address the issues. <p>Good luck! If you give this your full effort (attend the meeting totally prepared) no matter what happens you will always know you did everything!
   — zoedogcbr

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