I need help with an appeals letter

In an earlier post I told you guys that I was denied. So I called my Surgeons office and spoke with the surgery coordinator so that she can do the appeal for me and she stated that their office don't do appeals. WTH. I have never heard of this before. She said that I would have to call them my self. OK. I can do this but now I don't know where to start. I need help writing an appeals letter. Is there one out here that can help. I was denied beciase I wasn't over the 35 BMI with two co morbitities for about 6 months with in a two year time span. I lost 40 pounds but they can see that I gained it right back and then some. I have always been overweight. Please I need some guidance. I don't know where to start.

Who's the insurance carrier?  I've never heard of a surgeon not assisting with the appeal...that is really horrible.  I'm going through my second appeal now.  I am very familiar with insurance, and may be able to help a little. 

do you have any co-morbidities?  have you gone for a sleep apnea test? 

I have Aetna HMO. I have two comorbities. I have high blood pressure and diabetes. I also have PCOS.  I did a sleep study a few years back and I had slight sleep apnea. I haven't went back recently though. I have a current BMI of 39.7 and fits within the insurances range of a 35 BMI with two co-morbitities

I was denied on the grounds of the VSG being investigational, so I don't know how helpful it will be, but you're welcome to take a look at the letter that got my rejection overturned.  The bulk of it is making the argument against the investigational call, but you could pull out anything you think could help.

Good luck!

Thanks little miss sunshine.

The doctor's office was correct, they do not do appeals. You have to do your own appeal. You have to advocate for yourself. What your doctors office can do is tell you, based on your history and your lab numbers what you are at risk for or conditions that you currently have been diagnosed with that cause or contribute to more serious conditions. If you want to send me an email your letter before you send it off, I will gladly take a look at it and tweak it for you. If you respond to this post and send me an email I will share my email address with you. I write proposals and it may be helpful... Whatever you are comfortable with. JR

Let me know if you got my email. jR

Littlemisssunshine that is quite the letter, holy frig.  I don't have to worry about appealing as in Canada it is covered if the surgeon believes you are a candidate but the wait list is VERY LONG.  My doctor is still fighting with me about my decision but I think if I handed him a letter similiar to that he will know I am serious.  I have to go have a bunch of tests done before he will refer me to the surgeon :( but I know I am falling apart in the meantime, I can barely walk with my joint pain, back pain and foot pain.  My BMI is 42 and getting so frustrated and waiting for the results of all of my tests and hopefully I will have more reasons in needing this surgery.  I just feel like I would just gain back any weight I lost at a slow rate plus more`as I have in the past. Good luck with your appeal.

Hi Rekeca, I did not hear from you to assist with your letter and wanted to make sure you did receive my email address. It's still an open invitation if you want the assistance. [email protected]

Hi REkaca,

Please see my blog for excerpts from my appeals. My denial grounds were a little different, but see if any of it helps. I finally just got my approval so it can be done!

Good luck!
Hollyhock