Medical Review Board 2nd Denial

Well I recieved my second denial from my Insurance Co Med-Pay. She first said that it was denied because my BMI had just reached 40 BMI which is there BMI for surgery. So I protested and wrote a letter to the Medical review Board of Med-Pay and I receeved the second denial from them stateing that BMI hasn't been consistanly 40 or above long enough. I have been at 39.2-39.8 for about 5 years? But 40 evidently is the magic number. They stated even though I have the hypertension, borderline sleep apnea, acid reflux and diabetes and a really bad family history that my condition are beng treated with medication which appears to be working at this time. SO NOW WHAT DO I DO????????????????

The only thing I can think of is see a lawyer who specializes in weight loss surgery denials. There used to be one who advertised on the internet. Google and see if anyone comes up. I'll keep you in my prayers.
Hugs,
Lana

Dr. Hornbostel reccomends www.obesitylaw.com as a great site for fighting denails.  He said that this attorney had WLS and his wife has had WLS and he's an advocate for the procedure.  Dr. H said that he's heard of insurance companies seeing his stationary and saying, "Do it!" instead of dealing with this attorney... Hornbostel raves about this guy.  It couldn't hurt to look into it and/or contact him.

Best wishes, I can't imagine how frustrated you must be!

how long do they expect you to have a bmi of 40+? that would be important to know, plus they will also (probably require a 6 mo. supervised diet) and you would probably fall below the threshhold after that. I would plan on from now on getting some rolls of quarters (LITERALLLY) to go in your pocket for every dr. visit, I know others have done it. good luck, susan

They actually were going to wave the 6 month requirement since I had seen my own doctor and had done basically the same thing since June of last year seeing her every month due to my high blood pressure and blood sugar. I don't know how long. I wish I could send a copy to someone that knows how insurance companies work because they stated that I could appeal the company my husband works for (which is Coca-Cola) which is great for weight loss(not) since they are self insured. Any suggestions would be great!

Since they will waive the 6 mo.diet requirement, consider 6 mo's reasonable, just call and ask them how long you have to be at 40, don't hang up until you get an answer, get the persons name and ask them to send put it in writing and send it to you for your records, don't get discouraged, it can take a long time, but unless they have an exclusion(they don't), you WILL get there. but make sure you alway's keep a record of everything said and by whom, it can really be a life saver if you have to take further steps! p.s I would also look very carefully at your companies written policy on wls is it specific on a certain bmi? and does it say you have to be at that bmi for any length of time? if not ,say that when you call, tell them (nicely) that it say's nothing in the policy about any specific time to be at the magic bmi number, and you don't want to have to pursue legal avenues, but if they aren't following their own rules..or it appears that their making them up as they go...well you get the picture , just be as nice as possible more flies with honey and all that...remember before you mention legal help. WRITE DOWN THE PERSONS NAME!! very important, no one wants to be the cause of legal action for their company especially if they lose, say thank you for your time"mrs ,ms, mr, so and so " gently reminding them that THEY are responsible for their words-legal action. I guess that was a long P.S lol

The only person at Med Pay that I have talked to is just the one lady Terry whom is very nice and we have talked at great lengths. I just get the feeling she is really against the surgery personally. My policy say .... Weight Management/Control Charges for weight-loss programs will be covered if the program is necessary to treat a medical condition by decreasing the patient's weight. This program must be designed to treat health problems associated with high-risk Morbid Obesity/Severe Clinical Obesity and be administered and supervised by a Hospital or Physician's clinic. These heatlh conditions may include hypertention,diabetes,cardiovascular disease,sleep apnea and degenerative joint disease. The Covered Person must have demonstrated unsuccessful results in a weight-loss program. Coverage is limited to Medically Necessary charges for treatment of Morbid Obesity/Severe Clinical Obesity. The weight management must be expected to produce a significant improvement (reduction of weight by 10% if weight at time  of evaluation every six months) of the Covered Person's condition within a six (6) month period. The need to continue the care and regimen established must be documented in writing by the Physician for each six (6) month period. Benefits will terminate when the person's body mass index (BMI) has decreased below 30. In order to be eligible for gastric bypass, the Covered Person's BMI must be 40 or greater. Other than that the only other thing in the whole policy book it says for  Plan Exclusions Obesity. Care and treatment of obesity, weight loss or dietary control. Medically Neccessary charge for health problems associated with high-risk Morbid obesity/Severe clinical Obesity will be covered. I might add I pretty much have all the health conditions. My mother has coronary heart disease and has had several strokes. She has had a quadruptle bypass and currently has 8 stents. She has had 1 major stroke with damage and 3-4 minor strokes where the stroke was caught in time for medication to be administered to reverse most of the damage. She also has all the above for sure. She is also severely overweight. Thanks 

The only fly in the ointment is where it say's it must be to treat the co-morbidies, but they are under the impression that your co-morbidies "under control", however they did not say anything at all about they length of time one needs to be at  40 bmi , if you have all the letters and  dr notes with your weight, the reason that he-she feels the surgery is neccesary. Take everything highlight the relevent parts, esp. your bmi. Then take your policy and highlight everything it say's is needed, try to send it to the same person who denied you,( make a copy) tell them to please show you where in the policy it states you have to have a bmi of 40+ for any length of time. Tell them also you do not want to be forced to pursue legal matters but unless they can prove to you that you have not met their requirements, that you will have no other chice but to do just that, send it certified and wait, if that doesn't work, you will have to contact an atty. which your ins. will have to end up paying for if you win. If they ask you to wait 6 mo's to stay at that weight, it would be worth the wait because it would probably take that long to get through the court. Good luck and keep us us updated. good luck , susan