Appeal

I talked to the insurance company and they told me that the reason they denied me is because I have no documentation of FAILED attempted weight loss in the last year.  They wanted documentation from my doctor.  So I told them I had to be medically supervised for a year and not just the three months.  She denied it.  So I don't understand what she wants.  I am going to appeal and am presently getting my medical records from my physician's in NY to show that I have a history of attempted weight loss in the past on multiple occassions.  I have my appeal letter done (thanks Nan). 

I talked to my physician and he told me that if I wrote the letter, he would read it and sign it.  If anyone has any suggestions on something that might be beneficial in this letter, please let me know.  Nan, I do have yours and plan to use it.  Thanks for that too...

Thanks for all your support and help during this frustrating time....

You may want to ask your ins. co. for a copy of the WLS requirement portion of your contract. 

There may be something specific they are looking for that the representative isn't making clear to you.  For example, my ins. co. required 6 consecutive months of attempted weight loss with in the last two years.  Perhaps the sticking point is that your doctor visits weren't consecutive months, or perhaps too long since those visits to qualify.

I also don't follow why you told them you had to be medically supervised for a year and not 3 months.  It sounds like you are telling the ins. co. you think you need to attempt for a year and they say 3 months?

Yes, I would definately ask for the portion of your contract that states the requirements for surgery.

Best of luck to you,
Paula

No according to the surgeon, the insurance company wants three months of a medically supervised exercise and weight loss program, which I completed.  The reason why they denied me was because "I don't have any documentation of failed attempted weight loss in the last year,"though I do have plenty of it in the past.

How do I prove it if I tried but did not see a doctor for that specific reason is what I asked the insurance company.  I don't go to the doctors unless I need to.  If I am attempting to lose weight on my own, I didn't think I needed to see a doctor for it. 

I am lost as to how to fight this denial.  I am presently getting all my past medical records and prove that I have failed attempted weight loss in the past on multiple occassions.  In the last year I tried to lose weight on my own but did not see a physician for that.  How do I prove that.  I guess I could get an affidavit from some of the people at work who were trying to lose weight with me.  We were doing a "Biggest Loser" contest.

Forgive the length of my post, but it sounds like what I had gone through.  I had been discussing weight loss with my dr. over myriad years and it was documented, but none were medically supervised or for 3 consecutive months in the same year.  Unfortunately, the ins co doesn't care about the past if it doesn't fall within their guidelines and if they want medically supervised, they don't care what you did on your own, or with friends either because I did all kinds of programs through my gym which also included nutrition classes and food journaling in addition to extensive workouts. 

If I were you,  I would see the dr. for the 3 mo's while you fight it because it could take more time and effort to fight it than to just do your 3 months.  If you win great, if not, you have some of your dr supervised time in.  You are lucky, I had to do 6 months and my deductible is $3000, so all of it was out of my pocket.

 My bariatric surgeon provided me with a form for the dr to fill out to fullfil my ins requirements.    They also gave me a lengthly form I had to call my ins. co. and get all of the answers to including a copy of the portion of the contract regarding bariatric coverage requirements. 

For my documented medically supervised weight loss program, my dr. had to record date of visit and a ton of other info including what  program we were following.  The ins. co. wants alot of documentation.  In fact, I am going to run and grab one of the forms for Medically Supervised Weight Loss Documentation ...

Here's the info required to be filled out on the form at each visit.  (By the way, mine had to be 6 consecutive months so be sure you go for a formal dr. visit in each of the 3 months.  Just showing up for a weigh in did not count, I had to see the dr. for an official visit!

Pt. Name._______  Date of Visit________   Weight_______  Height (first visit only)     BMI_______   Blood Pressure_______ Heart Rate_______ Pulse________

Diet(Prescribed caloric restriction, review of dietary intake and recommendations_______________________________________________________
Type of Diet Recommendation______________________________________________
Physical Acitivity(Physical Exercise program appropriate for age, physical condition, including expectation for compliance adn recommendations)______________________________
Recommended Exercise Goal_____________________________________
Behavioral Intervention(Specific strategies and tools for overcoming b arriers and improving dietary compliance, for example log books, support groups, stress mgmt., social support_________________________________________________________
Pharmacotherapy (This must be addressed and documented.  List FDA approved weight loss drugs and strength or indicate that patient is unable to or refuses pharmacotherapy)._________________________________________________________
Physician Signature_______________________________________________________

There were examples of answers as a guide for the dr on the back of the form.  In the months that we were following the same protocol my dr. was able to fill in the form by just writing in "same."

Honestly, it'll go by before you know it.  I'm not trying to be a Debbie Downer, just trying to help you from a possible futile fight with the ins co where you may still end up having to do the consecutive 3 months.

Wishing you the best,
Paula

I already did the three month medically supervised exercise and weight loss program. They are looking for a year prior of failed attempts. I have tried to lose weight during that year but was not seen by a physician for that. So am working on ways to prove that I had some unsuccessful weight loss over the last year. I am also showing g a history of unsuccessful weight loss by getting my medical records from previous physicians.

Hi. I'm just wondering from the way your wrote your post if the insurance company didn't get any documentation from your doctor at all. I would call them again and clarify, if that is what the problem is. It can happen when things are faxed, that some things don't go through. It's just a thought. I hope it all works  out for you.