Help! Priority Health Denial

Looking for suggestions , experiences with Priority Health denials.   Has anyone had any luck with a grievance or 2nd appeal specifically to Priority Health?   Has anyone hired a lawyer?  Did that help?  I found Gary Viscio on this site as legal help on the insurance page.  Apparently he had a RNY and now helps with appeals.  He answers people's questions on the insurance forum.  Has anyone used him?  Were you happy with his services?  He is out of New York but says he can assist in any state.  He charges $450 for a basic appeal.  Any suggestions are greatly appreciated! Lynn

I don't have any specific experience with Priority or with Gary Viscio, but have some random thoughts that may or may not be useful... What exactly are Priority's co-morbidites per their criteria? I would call and get it in writing from them directly. Ask to speak with the case manager of your case directly, the people in customer service won't know and generally don't offer to have you speak to the people in the know. If they don't have specific ones listed in their criteria, then possibly a second opinion from another surgeon stating that your reflux is a co-morbidity might help your case on appeal.  I would shop around locally for a lawyer just to see their prices as they would be more able to be at the appeal in person which I think would be better. (Not sure that that is necessary, but just my opinion.)  HTH at least some. Hope you win on your next appeal!

Nancy, Don't give up!  I think the insurance companies deny people because they are sure you will give up trying easily.  I had to appeal my case, which at the time seemed pointless.  I did it anyway and got approved.  I had to have MMPC (Dr. Kemmeter) call my insurance company and go over my health records.  He had to point out my previous weights and ridiculous things that the insurance doctor should have been able to see. My advice is, wait on the lawyer and see what you can do with MMPC to get yourself approved. Jenn

Nancy,    I have no experience with Priority Health, but I did have a not so fun time with Aetna.  I was denied at first also and thought about a lawyer... lucky for me Aetna will allow you to appel unlimited times so I tried myself first.. and guess what iIWON!  I can gladly send to you what I used as my appeal.. basically I wrote a personal letter as to why I needed/wanted WLS.  I then took Aetna's clinical policy and picked it apart piece by piece to show exactly how I met the criteria and where exactly the evidence could be found in my medical records.. when all was said and done there was NO way they could say no.. it was all there in black and white.

Again I will gladly share with you what I did, just email me.  It took a little time but was WELL worth the investment.

DO NOT LET THE TURKEYS get you down!   They want you to walk away and give up... DON"T!

~Erin

Start 285

Current 143

Goal 135 (I know I'm 5'10" but this is MY goal darn it!)

9/12/05

Nancy... This is not looking good for me.. I have Priority Health and I am just in the begining stages of getting the Lap Band.  PH approved my surgeon appointment that I have on June 8th.  I hope I do not get denied from them.  I have several co-moribities.  If I get denied I will appeal once and if get denied again, I am just going to pay.  I cannot wait any longer.  I have to get this done.  I'm miserable!!! I wish you luck on the Insurance thing.. APPEAL APPEAL APPEAL!!!  Please keep me posted so I know what to expect.

Jodi Oh what difference a day can make!!!!!  I was denied twice.  I filed a grievance (very thorough) and brought it right to their buiding on Wenesday at 1:00 on my lunch hour.  Sometime that evening, they called my doctor's office and said they were reversing the denial!  Isn't that something.   Anyway, I am now approved and got my date on the same day.  It's June 22nd and I am obviously thrilled!  Good luck to you Jody.  You said you would give up after one appeal but I would at least try a grievance after that before you shuck out all that money. Lynn 

Oh wow.. I am so thrilled for you. .. Im envious!!!  I just dont know about the appeal....I dont want this to drag on longer than it needs too.   Okay I have a question.  Did PH make you go on a 20 wk diet?  i called them yesterday and they said that is what most Dr's have you do.  I dont want to do all this crap.  I just want the band!!! And again.. Congratsulations!!!

The best advice I can give you is get a copy of your company policy and read the sections on obesity.  I also got PH's company policy.  I can e-mail it to you if you wish.  I think that is how I won the grievance.  I quoted and attached their own policy on what is covered.  When they denied me they quoted half of a sentence, and conveniently didn't add the rest of it and that second half is what I fought for!  It seems unethical what they do.  But I now really believe what people say here is that they try and bluff and deny and hope you will go away.  But then again who knows, they could just approve you right away.  My doctor also had the qualifications right there when I went there.  Are you going to MMPC I assume?  What doctor? Lynn

Yes I would like you to email that to me...I sent you a private message with my personal email address...I was accepted to go to MMPC but chose to go to another Dr.  He is closer and I know some people that went to him and are pleased.  He is on 44th and Byron Center and his name is DR Beane.  I just got my approval in the mail today to go to him.  Cant wait.  I just know he is going to want to shapen his knives right there and perform. :O) I have read my Co. policy and it states the allow ONE WLS a lifetime and only cover 50%.  But if the dr says i really need it.. with they cover all?  Or is it always just going to be 50 %?  That is a question I do not now the answer too....Hmmm.. Thanks for all your help!

Jodi, i have PH also and was approved with a BMI of 52 with Diabetes and Sleep Apnea as my co-morbs.  It will really depend on what your stats are.  I think that Priority is getting better about approvals. Heather