I need your help Please

I am working on my 2^nd appeal to overturn my denial.  In my first denial I focused only on the legal issues and on this one I am going to add into my letter the personal reasons.  Here is a rough draft of what I learned from my multidisciplinary program that was required.  I am hoping to show what I have learned and what I have put into place in my life. 

 

Please give me your thoughts and if you see something that I have missed please let me know:

 

 

Attached you will find the full documentation from my multidisciplinary program.  I know you there are details from all of the people I talked to but I also wanted you to know what I learned during this.

 

• First and foremost from every person I talked to told me that this is just a tool, it is not a cure all end all and that I have to work hard if this is going to be a success.
• That the portions that I have eaten in the past are much larger than the amount someone should eat.  The plates we get when we go out to eat typically is two or more servings.
• Eat the right foods a more balanced diet.
• When eating meat see to it that it is lean and it has been grilled, baked or broiled and not fried.
• Eat more vegetables
• Eat fewer carbs
• Make Better Choices
• Eat a grilled chicken sandwich not a burger
• Have a side salad in the place of fries.
• Use corn tortillas in the place of flower.
•  Look at the labels at the store and pick the better food choices.
• Ask myself is this food that I want worth the calories or fat that it contains.   
• Use turkey bacon
• Eat more fish and seafood (just don’t fry it or cover it in a heavy sauce.
• Have some whole wheat toast in the place of those biscuits.
• Drink water not soda
• Find better ways to add flavor other than adding fat.
• Spices
• Lemon/Lime juice
• Use my home made salsa to flavor things
• Marinade meat and cook it on the grill
• When I make tacos use lean beef or ground turkey
• To stop eating when I am satisfied not when I am full.
• Don’t transfer stress to eating find something more productive to do.
• Read a book
• Go for a walk
• Listen to music
• Play with my son
• Take smaller bites, after my surgery I will need to eat my food cut to the size of a single six sided die.

• Slow down don’t eat so fast.

o       After each bite put my fork down and hands in my lap when I am ready for my next bite pick up my fork and take that bite

o       Sing happy birthday in my mind and when I am finished I can have another bite (This makes conversations difficult)

o       Get an egg timer and turn it over after each bite when the sand is gone take another bite

o       That when I eat slower I will feel full after eating less food

• Diet alone will not get me there I need to exercise

o       When I am going to the second floor in the office take the stairs not the elevator.

o       At work or at the store don’t try to part so close.

o       Find activities such as going for a walk to replace sitting in front of the TV.

 

With all of that said here are some of the changes I have made in my life since I started on my journey.

 

• There are none of the “bad foods” in our house.
• I cook grilled chicken not fried chicken.
• When I go out to eat I make the right choices.
• I have joined the YMCA, met with a personal trainer, and put an exercise plan in place.
• I don’t drink regular sodas, when I have a soda it is a diet one but other times I drink water, decalf iced tea sweetened with Splenda, and the calorie free additives that can be added directly in my water bottle.
• I don’t stop at the doughnut shop on my way into work
• I don’t go to the fast food places for lunch I go to the Y.
• I don’t graze at the office;  there are no bad snacks at my desk and I don’t get them out of the vending machine.

 

Scott:  I see that no one has answered, so here is my 2 cents...probably not even worth that, but as a nurse and having spent some time on these boards...this is what I think.  My impression is that insurance companies could care less about us as people, so personal appeal letters usually fall on deaf ears.  The more legal/scientific/medical evidence that can be provided will get your appeal looked at more seriously.   Since you now know everything reason they are giving regarding your denial, you should address these reasons individually and use scientific research to back up your opinion as much as you can. (You may have already done this, I don't know what your first appeal contained, of course.)  I think that most of the personal stories/information are ignored as they do not really want to look at us as people.....we are intending to cost them money and they are intending to make it as hard as possible for us to cost them money, if you know what I mean.  Also, they have no way of verifying anything that you are listing, its just a subjective statement from you.  They want objective evidence that you really require surgery to maintain/improve your health and that your obesity was longstanding enough that it is unlikely you could lose the weight in a traditional manner. I'm not saying that you shouldn't give them some indication that the multidisciplinary program worked as for as you are concerned, but they may not need all that detail about it.  I know you mentioned in a previous post that one of the reasons was that you did not have consecutive weights from the last 5 years to prove obesity, so if I were you I would concentrate on seeing how I could support a position that you were obviously mobidly obese the entire time, even if is not noted in your medical record for that year.  If you need to...you could go so far as to get a couple of certified affidavits from your physician or someone that knew you during that time frame, who will be willing to state that you did not somehow become a normal BMI between a one year time span.  It certainly couldn't hurt in that regard.  That is more objective than a personal statement from you.  Obviously don't use your wife or relation, but rather a medical professional or maybe someone that has known you the entire time and can give an objective statement. Let me state that I work as a nurse in a defense law firm and it is my job to produce evidence to a panel of doctors who decide medical malpractice cases.  A lot of people that file a lawsuit mostly on the basis of personal statements (i.e. the family remembers this or that was said or not said or done or not done) will go on to lose that suit.  The doctors are not taking the personal stories into account, but rather what the actual medical record references to make their decisions.  I feel that this is pretty similar to what the insurance company does when deciding whether to deny a claim or not, but I may be way off there...maybe my profession has altered my judgment, but I think the more factual you can be and the less personal..the better.   Good luck with your appeal!!

Angela,

 

I know where you are coming from there and that is exactly how I did my first letter.  Being an insurance claims examiner (P&C) I filled the first appeal with legal reasons, I documented everything that they denied my claim for the first time.  I quoted the ERISA law and provided medical documentation back to 1997.  I was shocked when my appeal was denied.  I also know what you are saying when this costs the insurance money.  In this case it does not, our plan is fully covered by the company for the first 500,000 per person and Aetna is the TPA but they do have their fiduciary responsibility to the company I work for.

 

I guess the reason I wrote the letter this way is that my first letter came off very cold and to the point just like the demand packaged and legal pleading that I read every day.  But I thought back of some of the demands that came directly from the person who actually was hurt and when they put it on a personal level I can honestly say some of it actually stuck. 

 

I also guess I forgot to put in my posting that this is only the personal part of my appeal letter.  The first part of the letter is going to go over in detail the two reasons they denied my claim and the appeal and provide medical documentation.  I guess this part is just attempting to put it over the top.

 

But I completely understand where you are coming from.  Thanks for reply, I thought no one was going to say anything. Scott

Now that I'm clear on the fact that you have already covered all the medical and legal issues then I would say that the personal part of your appeal would be fine.  They may not pay attention, but it sure can't hurt and may even be helpful as a backup to the evidence you're presenting.  It definitely shows your level of committment to the future lifestyle change you will need to undergo. 

I will by praying that your 2nd appeal is successful and that you are able to have surgery sooner rather than later.  Good luck.

Hey man, Listen,,first I want to say that Im not a lawyer, Im not a doctor, and I have zero experience with insurance. But, if you read my profile, you will see that I too got denied twice, and had to go to a state approval meeting with the headquarters of my insurance. I won, and I will tell you how. First thing,, your letter is very personal. This appeal session, or wait, MY appeal session was NOT personal. What got me over was that I had an attorney, who had experience working with these insurance companies AND he himself got wls. It was Gary Viscio. When the insurance company came in with THEIR panel of surgeons, and lawyers, and appeal people, they TRIED to steer to conversation to their benefit. My attorney let them know that they had a LEGAL obligation to provide coverage. He also let them know that past histories of the success rates of wls had no bearing on MY case. In short, get you a lawyer and let the insurance company know that you are NOT going away. Thats what they want anyways. Steve Que