My 1st Appeal - Denied

[Shelby 0]

This process is so frustrating and emotional but I'm not giving up. I have Cigna Insurance -- the lapband is covered in my policy and I meet all of their criteria but am still denied. The first denial was because my surgeons office didn't submit all of my doctors files - yup! I was denied for stupidity :-) The 2nd time we submitted the info I was right there at the fax machine so I knew that everything was submitted. But when I called Cigna this morning I was told my appeal has been upheld. They couldn't tell me why and will have to wait for the letter from the National Appeals Unit in California.

I've been working on this for a year now - since March 05 (Surgeon Seminar, surgeon appt, 6 month primary physician appts, pysc eval, nutrientist, sleep apena study, upper GI tests, denial/appeal) and my appeal is upheld - I don't get it.

My plan is to wait for the letter and appeal it again. This is my health we're dealing with and I'm not going away or giving up.

[banded_for_life 2]

You keep up the hard work...I know how frustrating the waiting can be. I am sure the tide will turn your way...just don't give up!

[Mvpo8961 1]

Let us know what the ins co says. You might want to check with ReneBean after you get your letter. She had to appeal to the state of California because of denials from her ins. I believe she had BC/BS. But I know she has shared with some others her letter of appeal that she wrote. She won her case. GOOD LUCK. M

[Shelby 0]

Thanks for your help and support. I will keep you updated.

[disneynut 0]

My sister was just denied through her insurance company Connecticare. They told her they couldn't give her specifics as to why she was denied but to call her surgeon. She has been trying for almost a full month (10 + messages left with his assistant) and she cannot get the assistant to return one phone call. Will she be receiving a letter of denial from her insurance company and then what is the process for appealing a denial? Does the doctor's office usually help a patient in dealing with the appeal process or do they just move on to the next patient.

[Alexandra 55]

It's SO frustrating, dealing with insurance carriers! My heart goes out to both of you. It may take time but I'm positive they MUST disclose to you the reasons for any denials of coverage. If you don't get a letter with details within two weeks or so, complain to your state insurance or health department. (One of those departments will be the one with jurisdiction over HMO organizations; try searching your state's website for Consumer Health Insurance Complaints or something like that.)

Shelby, if your carrier is saying they need more information or something, that's not a true "denial" and can't be counted against your appeals. It's simply an "incomplete." Keep plugging away, and start counting the denials frlom the moment you know your carrier has ALL the information they need to make a determination of medical necessity.

Good luck!!

[Shelby 0]

Thanks Alexandra. I received the letter from Cigna and it was about as clear as mud! The letter was regarding gastric bypass surgery @#$%! and it said if I wanted to submit more info they will look at it but it was not an appeal nor was it a denial letter either -- it was completely the wrong letter!

I called Cigna and was able to speak with a rep who sounded like she knew the process. She agreed - the wrong letter was sent. Because LapBand is an outpatient surgery there is not appeal process for pre-determination (only in-patient surgery has an appeal process). My info was sent to the appeal unit because I included my 1st denial letter with my package (I was just following what the letter said) and one look at the denial letter and it was shipped to appeal. Oh boy.

So now my plan of attack is re-submit without including any Cigna letters. Along with a letter from me to Cigna -- I'll write it this weekend and fax everything (again) to Cigna and wait another 30 days for a response. Wish me luck!

Disneynut - my surgeons office has a Lapband Coordinator who is helping. But take my advice - make sure your sister is all over the details even with the coordinator (I had to learn my lesson the hard way). And yes the surgeon will receive the same letter your sister does from her insurance company. Sounds like she is falling between the cracks -- may require a walk in chat. Speak up - get involved - stay on top of it. Best of luck to her and to you for being a great supportive sister!

[NewDay 0]

Help me please! I've been denied based on medical necessity. I have to write an appeal. Does anyone know what the insurance company needs to know for a successful appeal. I can write a life story book, but really only want to let them know what they're looking for. What does an appeal look like?

Thanks DisneyNut. I know you're talking about me. Love you too!

[kabasm 0]

Depending on what was already submitted to the insurance company, it would be beneficial to include:

1. Current weight, height, BMI and existing co-morbidities. Remember that most insurance companies are looking for a BMI of 40+. They will also consider a BMI of 35-40 if the patient has existing co-morbidities.

2. All attempts at loosing the excess weight, i.e., program, how long on the program and amount of pounds lost. Did you re-gain the weight.

3. How long have you had the obesity problem, i.e., since childhood, since giving birth - and for how many years. Take into account that if your weight problem was a recent thing – that is you gained 60 pounds last year when your child was born – they will not see this as a “life long problem” and assume you can loose the weight on your own.

4. Family medical history that because you are overweight will predispose you to further medical problems.

5. Try and also have your surgeon write a letter of medical necessity to be included in your appeal.

6. Consider the medical reason they denied your surgery and state the reasons why they are wrong. Be factual – consider the audience. If you can, try to have a different nurse/doctor review your appeal – that is other than the one who issued the denial. Ask for the credentials of the Doctor/Nurse who denied your request to see if they have experience in Bariatric surgery/Lapband/WLS and understand what is involved. For example: I would like to know whether the physician making this determination has appropriate clinical experience in WLS. Also, a copy of the criteria that was used to determine the disposition of this request will also be appreciated

Style of your letter should be business with re. line stating your name, insurance ID # and that this is your appeal. For example, I am in receipt of you letter dated….and I would like to appeal your determination denying my weight loss surgery.

I hope this is helpful and good luck. Things have a way of working out.

[Alexandra 55]

Wow, kabasm, that's great information!! Do you work for an insurance carrier?

[ReneBean 3]

Hey Guys - PM me if you want to view the letters I used to beat the system. I was denied for the Band because I am too fat!

Since that is patently ridiculous, I was able to beat the system - but not quickly - and not without an INDEPENDENT MEDICAL REVIEW by the State Insurance Board.

And DON'T wait for your coordinators more than a day or so. If I had waited, I would still be waiting, now.

PM me and I will be happy to send you the appeal letters I used. Maybe they will be of some help.

Keep Fighting! Good Luck.

[kabasm 0]

No, I do not work for an insurance carrier. However, I used to work for a doctor (pain management) and I would write the letters for the patients in order to get their treatment approved/precertified/authorized.