Medical Necessity But Still DENIED

So I got a new letter today from the insurace company and here is what they have said 

 "According to your specific benefic plan, bariatrics surgery is only covered by an in-network provider. Upon review of the information submitted, you have met the medical necessity guidelines criteria for bariatric surgery. As noted above; however, such surgery would NOT be covered by the provider being requested as he is out-of-network. The information received does not support in-network coverage of bariatric surgery by this out-of-network provider. Similar services are available in-network and no compelling medical reason has been given as to why an exception should be and this request authorized."

But no one in-network offers DS and no one in-network will help me unless my BMI is 58 or less and mines 82 I have contacted everyone in california on my in-network list, also the insurance company gave a name of a in-network doctor they said does DS and to go to him so I contacted his office and he doesn't do DS and won't do anyone's surgery over a BMI of 52 but when I asked if I could get that in writing they said they don't put things in writing like that. So i'm not sure what to do next but appeal it. Any suggestions would be greatly appreciated thanks :)

You might try contacting your insurance company and explain to them what the doctor's office said and then ask them, since the doctor is unwilling to put his policy in writing and his policy seemes to be contradictory to what his office is telling the insurance company, if they (the insurance company) would be willing to participate with you in a conference call to the doctor's office.  That way the doctor will have no alternative but to either meet with you or tell you "no" on the phone.  If the doctor meets with you then he will have to open a file and the insurance company will have something on record.  You do, though, risk annoying the doctor (or at least his office staff) when you are trying to win them over to your side.  If he meets with you, you will need to put together a major charm offensive to get back into his good graces.  As my mother and grandmother always said, "you catch more flies with honey than you do vinegar."

Something to think about...

Good lucK.

Considering the cir****tances, I would hire an attorney to represent you in the appeal to the Department of Managed Healthcare.  The DMHC governs health plans that operate in the state of California and they are on the patient's side.

I appealed to Pacificare and the DMHC with the help of an attorney who specializes in these matters. You can contact them for a consultation at www.obesitylaw.com.  They were so fantastic and fought for me. I could have done the homework myself and do my own appeal but I don't know the system like they do. 

Good luck, and don't give up!

Hello I just wanted to ask a question....Since you have to stay in your network...do you have to get DS done? Can you have Lapband or RNY done?

Everyone has given you good advice, but I just want to say don't give up the fight sweetie!!! If this is what God wants for you, it WILL happen!!!!! Prayers are with you! bigg huggs, Becky

Go over to the DS forums and look for Diane Cox. She is a wealth of information in helping people go thru all this.

Good luck.

She and I are already corresponding on this -- it is UNCONSCIONABLE what the insurance company can put people through!

Thanks for this.