Question:
Has anyone been denied after an appeal? What do I do next?

I was denied twice. Once March 6th and we sent in the denial. I wrote a letter, my PCP wrote a letter and the surgeon did too along with documentation. I just got second denial letter today, which was dated April 12th. I don't know what do do next.    — nvgirl (posted on April 14, 2001)

April 14, 2001
Linda, It sounds like they just want documentation that you have tried several weight loss measures before deciding to do the surgery. I read your profile and you mentioned you dieted constantly. Just record down what type of diets you were on, Weight Watchers, Jenny Craig, NutriSystem, anything that they can use to justify this surgery. You didn't mention if they were denying for other reasons, so I'm assuming it is just for the documented weight loss. If you don't have anything to write down, get on one right now with your current PCP and stay on it for however many months will make them happy. Cigna approves quite a few surgeries, so it must be this one loop hole you have to get through. Good luck.
   — Dawn R.

April 14, 2001
I was denied before I got ahold of someone at the insurance company who finally told me why I was denied and what the requirements were. First, one of the requirements is that the patient be 100 lbs overweight. I thought I was but they (insurance company) were going by the largest frame and the heaviest weight on the Metropolitan Weight Tables. I weighed 250 lbs. but according to the tables, the maximum weight for my height should be 152 lbs. I actually had to gain 2 lbs., which put me at 252 lbs. so that I was then, according to the tables, 100 lbs overweight. Secondly, although I had been on many weight loss plans that I had documented and sent to them, they required that I had to be on a Dr. supervised weight loss plan for at least 6 months. That was easy as I had been on Phen-Phen for 6 months. I sent them my perscription records as proof. Third, the letter from the Dr. had to mention that I was morbidly obese and it was a threat to my health (sounds like you have that). I guess the bottom line is to find out just exacatly what your insurance company requires for the surgery and then do another appeal. My company (Aetna) said I was allowed 2 appeals. I hope it works out for you.
   — Mary C.