Question:
Has anyone appealed a federal ins denial through OPM?

My HMO wants me to have one more co-morbidity. I have lots of health problems, but not the one they want me to have. If you have appealed to OPM. Please e-mail me with your letter and their response. This is my last chance. The only recourse after OPM is the court system. The big boo boo is that I could have changed insurance companies and been approved for this surgery today. The government requires their insurance companies to cover certain procedures, but they let the ins. companies (my hmo) decide the medical necesity. Catch 22. If you can help me thank you! Maurine    — Maurine S. (posted on January 2, 2001)

January 2, 2001
Maurine, I did appeal to OPM and lost the appeal! I switched to Bc/BS during open season though so I am hopeful. Here is what I believe may help you, I lost my appeal because there were no DS surgeons in my network and I did not want an RNY. Because there are only quality of life issues and not weight loss differences that are statistically significant, the doctor who reviewed for OPM upheld their decision that I didn't have to be allowed to go out of network. I think if you can switch insurances still to go ahead and switch, if not then write to OPM. I will warn you, some of the people working with them, including the one I had, wasn't the most timely with responses. I don't know if he deals with all HMO's or just the ones in my area of PA. You have a good case and should be able to win especially if your surgeon is in your network. When you send things to OPM make sure you send all the information they need. If you have a copy of your letter of medical necessity then send it. My HMO didn't send it along with mine. I would also make sure you send the NIH recommendations and any other literature you can get.OPM will then send it out for review by physicians of which you will have no control. I don't however think the physicians will take the HMO's advice over that of NIH. Good luck, email me privately if you would like more direct info.
   — Jean S.

January 3, 2001
Hi Maurine!!! I also have BC/BS and they approved in two days. BC/BS is much more expensive bi-weekly than just about any of the HMOs, but for me it has been SOOOO worth it. I'm so sorry you missed the "window" to change. I wish I had something useful to give you. But the HMO I was previously a member of jerked me around just like yours. Hang in there and definitely DO appeal. It's worth your time. The other thing you might do is contact Walter Lindstrom. He has had quite a bit of success with HMOs. My best to you! Connie in Salem
   — Connie H.