Re-post for Gary please? - Diabetes or other rare disease needed????

Here is the first paragraph of my denial letter:

Please let me briefly explain how I made this decision. The clinical information submitted for review does not indicate that this patient meets the following PEBB bariatric surgery criteria. While you are over 21 years of age and less than 60 you do not have diabetes or another rare disease that would qualify you for the procedure. In addition there is no documentation of a psychological examination performed by a licensed mental health worker indicating your mental health status or ability to comply with pre-operative requirements and post-operative lifestyle and dietary changes. Also not included in the documentation is an assessment of your pre-operative physical condition or surgical risk assessment by a bariatric surgeon. There is no evidence of participation in a medically structured weight loss program with at least 5%

weight loss that must be maintained up until the time of surgery. And below is the PEBB Criteria: PEBB Plans The patient must meet all of the following: 1.     Age: Older than 21 an dless than 60 at the time of the procedure

2.     BMI: is equal to or greater than 35 WITH:

The denial letter is simply identifying the criteria that you have to meet in order for your health insurance company to provide coverage for the surgery.  The main thing that you have to meet is a substantial BMI, a co-morbidity (e.g. diabetes), no illnesses or health issues that would endanger your life if you had weight-loss surgery, and a medically supervised weight-management plan.  The rest of the information is about things that your surgeon would submit after those initial determinations have been made. There are times when an attorney should be contacted in relation to issues that people experience with obstinate health insurance companies or employers.  However, I find it irresponsible for your surgeon to immediately refer you to an attorney.  The implication that I get is that he feels that an attorney can wrangle the insurance company into getting you what you want, and that's not what it's about at all.  It's really about your health and safety.  If you met most of the requirements above, then I would possibly advise that you talk with a legal professional to ascertain your rights.  However, based on the information you provided here, there has been no medically supervised weight-management plan, and there are no co-morbidities. Of course, you have the right to appeal the decision, but the appeal will have to contain information substantiating the medical necessity of your particular situation, and it has to be in line with the coverage level your insurance company offers.  You also have the right to choose a different health plan, one that might have less restrictions on whom it will approve for the surgery.