Letter To Appeals Dept At Insurance Company

[nikkiluv 0]

Has anyone ever included their own letter to the appeals dept of thier insurace company? What information did you include? Did it help? I am going to my first seminar on 5/10. I haven't been denied yet but I am anticipating it due to my BMI being 39 with only 1 comorbidity. My particular insurance carrier (united healthcare) has recently changed thier policy to be "case by case' rather than having strict criteria. Just wanted to know what to prepare for.

[Sojourner 2,446]

Has anyone ever included their own letter to the appeals dept of thier insurace company? What information did you include? Did it help? I am going to my first seminar on 5/10. I haven't been denied yet but I am anticipating it due to my BMI being 39 with only 1 comorbidity. My particular insurance carrier (united healthcare) has recently changed thier policy to be "case by case' rather than having strict criteria. Just wanted to know what to prepare for.

I was not denied approval for the surgery, however the insurance specialist who reviewed my medical records prior to submitting to my insurance company told me I needed to write a letter to be included with the rest of my records. The letter was necessary to explain the reason why there was no weight recorded for me for nearly 1 out of the 3 years of records sent in.

I drafted a short letter, explaining why this crucial number was missing, and was approved with the first letter submitted by my doctor. My BMI was also 39.

Any weight related co-morbidity, especially one which requires you to take prescription medication will be in your favor. It's not just your current medical issues that are usually considered, my doctor also included the mention of my very high probability of developing Type 2 diabetes in the very near future (like within the 6 month window of having to complete the 6 month supervised diet).

I hope that you don't have your request denied, but be proactive to state your case to the insurance company if you need to...

Good luck! Please post on the outcome.

[Jen75 33]

I too had to submit a letter but it was required. I basically stated that at the age of 33 I was obese and had struggled with weight my entire adult life. I wanted to be healthy. I wanted to prevent co morbities like heart disease and diabetes. (which saves the i insurance company money). I also wanted to be able to enjoy life. It was kind of a heartfelt letter to myself and why I wanted to live a healthy lifestyle. I also explained that I understood that the band was a tool that I was to work and not a solution to all my problems.

I was 110 pounds overweight, high cholesterol, back and joint pain, depression, anxiety and have hypothyroidism. By explaining all of that and most of it was from my weight I was approved. Good luck with you letter and the journey you are just starting.

[Cocoabean 430]

I was denied the consult appointment because I hadn't done a 6 month supervised diet. I basically followed the appeals letter in WLS for Dummies.

My letter was about 5 pages long, full history of weight loss attempts and amounts lost and gained with times to regain. Weight related health history. Weight loss attempts records, weight watchers records and personal diaries. I then went into why I wanted the surgery which was to improve my health, improve my quality of life, and extend my life. To allow me to enjoy being with my family and not just watching from the sidelines.

I won the appeal and did not have to do the required 6 month diet.

[nikkiluv 0]

Thanks for all the help!! I am anxiously awaiting to go to the first seminar. My insurance company recently implimented some new guidelines that do not have a "criteria"" to meet. Its all case by case now. When I called the insurance company they told me that they just put this in place within the last 2 months. I am unsure if they require a personal letter but if they do I will be sure to take all of this advice and add it. The addition of how this will benefit my life, prevent future obesity related diseases and should be used as a tool are all very powerful things to include. I was wondering if I should also include that my husband has only been on the job for 6 years and we have a long time with this policy should be included. I assume if they are aware that it would make them benefit in the long run by not having to pay for other obesity related issues it would sway them. I also feel like because my BMI is only 39 that gaining the 8-10 pounds to make it a 40 BMI would not be beneficial.I am hoping not to have to fight it.

Thanks again!

[c945105 14]

Thanks for all the help!! I am anxiously awaiting to go to the first seminar. My insurance company recently implimented some new guidelines that do not have a "criteria"" to meet. Its all case by case now. When I called the insurance company they told me that they just put this in place within the last 2 months. I am unsure if they require a personal letter but if they do I will be sure to take all of this advice and add it. The addition of how this will benefit my life' date=' prevent future obesity related diseases and should be used as a tool are all very powerful things to include. I was wondering if I should also include that my husband has only been on the job for 6 years and we have a long time with this policy should be included. I assume if they are aware that it would make them benefit in the long run by not having to pay for other obesity related issues it would sway them. I also feel like because my BMI is only 39 that gaining the 8-10 pounds to make it a 40 BMI would not be beneficial.I am hoping not to have to fight it.

Thanks again![/quote']

I have UHC too but I really think it's based on how the companies policy is written. I my case policy said BMI of 40 and five year history of morbidly obese.... Well I met the 40 (just barely) and I have tons of documention as was on diet pills for 6 years (and lots of diets) which kept BMI just under 40 within 10 pounds. I was really disappointed as I wrote very detailed letters fighting the 5 year history as only reason under was clearly because was dieting not very successfully and felt my company wrote the policy that way to consider people like me or else they should have clearly just said a BMI of 40 for five years. I have comorbidities but not "severe" enough for them like apnea or hypertension. I have insulin resistance (requires metformin), high cholesterol , high triglyceride , and reactive airways) also have history of diabetes, apnea, copd with parents so not far off for me. Anyhow, I worked really hard on 2 appeals and an external review and all were denied. I went self pay sadly and praying for no complications (which is biggest fear going self pay).

I guess bottom line again is your company policy . I feel UHC has been instructed to not give anything with my company . I have won appeals on other things with them but had to spend incredible amounts of time I shouldn't have had to as they approved it initially (ST and OT for my young son). I've had several dr pull out accepting them recently for new patients. Anyhow, I'm bitter about it but moving on.

I wish you the very best and hope yours goes through. All good suggestions here for sure by others. I think it's probably good news it's case by case as you can build that strong case. Good luck!

[Cocoabean 430]

Someone I know has UHC, she just discovered they have the 5 year history requirement for her policy as well. She did not go to the doctor every year. So we are brainstorming ways to prove she was obese.