New to this forum: Insurance Appeal Question

Today I recieved a letter in the mail responding to my appeal letter. With my insurance there is a direct exclusion policy for surgery for morbid obesity. I appealed the denial asking for them to approve to cure my other conditions with this surgery being a means to do that. They responded with saying that they are giving me the opportunity to meet with the appeals committee. Is this standard procedure or does this mean that they may actually be considering it? I hope so. I'm a little nervous though to meet with the committee as I don't look over 100 pounds overweight. I hide it well, but am definately there and I feel it everyday, every hour, every minute if you know what I mean. Has anyone had to meet with an appeals committee before and if so, what did they do in the meeting?

Tricia; I've never heard of anyone being able to personally present their case to the appeals committee. Don't worry about looking less than 100 lbs. overweight. I used to think I carried my weight well, too and that I didn't look like I weighed 250+ lbs. Now I look at my pre-op photos and realize I didn't have know what I really looked like. And, if you're really that worried that they don't believe the weight in your chart, then take a scale with you and offer to get on it for them. Good luck at your appeal. Let us know how it goes! Blessings, Jennifer 253 / 159 / 137

Hello, I know that insurance companies are all about money. Try showing them how much they pay for you now and could pay if you had complication from your other health problems. How much it costs to have the surgery and eliminate the other health problems. Most insurance companies feel that it take at least two years for this surgery to pay for itself in the long run. Just an idea. Cathy

Everybodies appeals process differs based on their state and the policy. I have BCBS and my 3rd level appeal went to external appeals review - I did not attend the meeting but I was being denied for not meeting the criteria not for an exclusion. It is standard procedure for your insurance. Its hard to say what they will decide - typically when an insurance company excludes a procedure it is excluded - if your policy is ASO funded your company could give the go ahead and decide to pay for the procedure so that would be something to find out. The external review is typically done by people that do *not* work for the insurance company... sometimes its even reviewed by people that work for your company - the letter from the insurance comapny should explain further. As for what they do in the meeting, they review the information - if you are there they allow you to make a statement and ask questions then they decide - the panel is usually 3-5 people and will make the decision right then.