NOT MEDICALLY NECESSARY!!

Ok, before I was just really down... but now, as I think about it I get more and more angry!! I was denied the surgery two days ago, the insurance company was saying it's "not medically necessary since you don't have HTN, Diabetes, or sleep apnea" according to my surgeon's coordinator. So I got upset and called HR at my job because they are self funded insurance. Ok, I spoke to the HR person who handles our insurance, and I asked him for the information on the appeals process. He informed me that HE was the person to whom insurance appeals should be directed. He informed me that there is provision for only one appeal, which is reviewed by him (an employee of my company, in HR). He advised that I should be comprehensive in my appeal request and that I have 60 days in which to appeal. He also said that he then had 30 days to respond, but he thought he could handle the appeal much faster than that. He also stated that utilizing an attorney would be a "moot point" since the ruling on the appeal is final. It was almost as if he was hinting that he would overturn the denial... on just the brief data I gave him. Anyway, I'm debating using a ghost writer for the appeal, versus an attorney, versus just writing the letter on my own.... Opinions? Need to move on this quickly...

I should include that although I have no major comorbids, my BMI is 51.2 and I'm 34 yrs old with arthritis so bad I cannot walk at times.

Kat, What is HTN? Do you have joint problems due to your weight? That is basically how I got approved because I didn't have the other co-morbidities. Lori 384/274/170

HTN is hypertension aka high Blood pressure... Yep, major joint pain, visible arthritic changes in knees, recurrent falling...

Kat, What I did was have each of my doctors write a letter telling the insurance company that they did feel it was medically necessary for the following reasons: 1. I'm a breast cancer survivor. Mother has a history of stage 3 uterine and kidney cancer. (Obesity really increases your likelihood of developing cancer.) 2. Knee and hip arthritis that eventually would result in the use of a wheel chair. I was already using a cane by the time I had this surgery. 3. Both of my parents are SMOs. My mother has congestive heart failure and my father has HTN and diabetes. Neither can walk. They are only 61 and 62! I had my doctors put all that in the letters. Good luck! Lori 384/274/170 P.S. I work at a hospital here in Utah. We had the disaster recovery person come talk to us. I work in IT. She shared the story of a poor woman in New Orleans who was too SMO to leave her home. Her son decided to stay with her. The water kept rising. The woman began to float. The son actually used his mom as a raft to survive. They both survived. The whole auditorium got a good chuckle out of this scenario. I sat there fuming!

Kat, Well you do have enoough to go on...your bmi is well over 40...you have arthritis which will be made worse by the weight you are carrying...(do they want more bad stuff to pay for before they are willing to do the surgery??) also the more obese we are the higher the risk of cancer..whi*****idently i have already had and my bmi when i went to Dr. Coirin was almost 65. so if you have a family history that is also a good point that your risks are higher for all the problems due to your weight. Good luck..also check out mygastricbypass.com Peggy