I was denied twice by my insurance co.  On each denial, I wrote an appeal letter addressing exactly what they had spelled out as their reason for denial.  I had to take it point by point.  In my case, each instance they had one reason for denial so it was fairly simple to respond to that.  Basically you parrot their language a little bit.  Like when they said I had not been compliant with the 6-month doctor supervised diet, I replied I had followed the criteria set forth by my doctor and nutritionist's plan but I was unable to maintain the very low calorie diet plan due to my large volume stomach capacity.  In my doctor's office, we had to keep a diary of everything we ate, calculate the calories and an exercise log.  When that was presented to the insurance company on the first submission it's like they pistol whip you with that information so instead of getting mad and giving up (OK, I was mad & emotionally wrecked at first but I put on my big girl panties & fought back), I humbled myself and said (in my appeal) that this doctor's supervised diet was yet another example of a failed diet attempt and that the RNY surgery is what I felt was the best choice to help me in controlling my hunger thru reduced capacity.  I also listed all my health issues and how daily life was difficult for me.  You really have to put yourself out there in these appeal letters.  Defiance & threats won't work.  If you have met the insurance qualification criteria they have no choice but to approve you.  It's a hard and rocky road for some of us.  I really feel they are just trying to get people to give up.  Those that do simply means they don't have to pay out anything and therefore that money is in their pocket.  It takes a lot of medicine & dr. visits to accumulate to a $65k surgery (what my surgery would cost without insurance).  And we know these insurance companies are in it for the money, not because they truly want you to have a better quality of life.  Sad but true.  Hang in there girl.  If you are denied again and want help answering, contact me again.  I'll be glad to help if I can.

Check out the website for the insurance commissioner in your state.  There may be information on the site, such as a sample grievance form that you can use as a "go by."  If not, give them a call and see what they suggest.  The second source you can consult is the insurance company's own website.  They should have information for their insureds on how to file grievances and/or pursue appeals (also check any denial letter you received; I have Aetna, and they clearly state how to appeal a decision in the letter itself).  You might also ask your surgeon's office if they have a sample you could use, as I'm sure they've had other patients who have been in similar situations.

Try to make your grievance clear and concise, and be prepared to include any copies of medical records, etc. that show your BMI.  Good luck to you!

Hi,

Not a problem at all. I also was very blessing to have great support and a lot of new friends, who helped me along my journey.

Hugs,
Suzanne

I'm currently battling Aetna for approval for VSG, but I am afraid that because of a BMI not consistenly 35 or greater the past 2 years (even though I've had Type II diabetes & hypertension for about 6 years), they will not pay.  So, I'm trying to get an idea of "package" prices for docs in driving distance from Atlanta GA.  I've received info on a surgeon in San Antonio who will do VSG for $11,000 (includes hospital, anesthesia, follow-up) -- but I'd really like something closer so that I wouldn't have to spend $ on airfare. 

Anyone self-pay in Tennessee (Chattanooga, Knoxville) or Alabama?  Or outside of Atlanta? Any info on prices and how you liked (or disliked) your surgeon would be great.  Thanks!

Hi,

I love a person that asks a lot of questions.  Smart girl to do that.  I am always here to answer any and all your questions.  I want you to feel very comfortable with the answers and if you don't keep asking me OK. 

This is ALL about you and NO one else.  You have to do what is right for you.  I know you can become very successful and lose this weight.  If diet and exercise alone worked for EVERYONE we wouldn't have any fat people in the world.  We need something else.  There is NO shame in having weight loss surgery.  It takes a whole lot of courage to do what you are about to do.  I am so proud of you for starting this process.

Hugs,
Suzanne