Example of Appeal Letters

[Mrs Husker 3]

I have found that writing an appeal letter to very difficult. I kept forgetting things and had to go back and add to it. I also didn’t know what all needed to be put in it. Hopefully this will help others when they are faced with a denial. Maybe you "pros" can help "tweek" us first timers.

Please indicated what insurance you have/had, and what, if any, where the results you received after sending your appeal.:help:

I have BCBS of NE and I and just trying to get all my information together right now before I send in my letter. Any input would be most helpful.

__________________________________________________________

Name

Street Address

City, State, Zip

Member ID: XXX XXX XXX

June 9, 2006

Blue Cross and Blue Shield of Nebraska

PO Box 3248

Omaha, NE 68180-0001

Attn: Appeals Department

Re: Request for an appeal

Dear Sir or Madam,

You recently denied pre-authorization for laparoscopic bypass surgery (I am wanting Laparoscopic Adjustable Gastric Banding, Lap-band, surgery) stating that it was not medically necessary.

I was referred by my primary care physician, Dr. Stephen Budd to Dr Corrigan McBride for a consultation for this procedure. This referral is being requested because the lap-band is a medical necessity for me. I am 39 years old (DOB 2/3/1967), 5’ 1” tall, weigh 230 lbs, BMI 43.5. Desirable BMI is between 21-25 and desirable weight range for someone of my height and build is between 95-115 lbs. A BMI over 40 classifies me as being very severely obese. My morbid obesity has caused me continuing health problems such as high cholesterol and triglycerides, sleep apnea, colon polyps, irregular menstrual periods, shortness of breath with any excretion, bile acid reflux, urinary incontinence and pain in my back, feet, legs, hips and shoulders. Even with the c-pap machine, I can not lie flat while I sleep. I must sleep in an elevated position or have trouble breathing and wake up with such back pain that I need assistance to get out of bed. Lately I have notice that I have swelling in my feet, ankles and fingers. I also have kidney stones.

My obesity has been affecting my job. I have to be on my feet most of the day and must be able to pick up and move heavy boxes. The obesity interferes with my ability to have a normal life. It is difficult to clean house, to do yard work, stair climbing, exercise, sit in a theater seat, go for walks, and participate in family outdoor activities such as camping, hiking and kayaking to name a few.

I have tried many diets, exercise and medication over the last 20 years and just ended up heavier and heavier. In 2005, when I hit 212 lbs, I went on L.A. Weight Loss. I did lose close to 30 lbs and was down to about 180 lbs. In less than one year, I put the 30 lbs back on and have added 18 lbs. And after each failed attempt at weight loss, my medical problems mount.

The surgery would enable me to lose weight, improve my mobility, enable me to stop taking or reduce the amount of my medication and I would no longer need my c-pap. I have the full support of my physician and family. They all feel this is the best decision for me to improve the quality of my health and my life.

Sincerely,

[3loves 0]

Hi Barb, I think you've put together a very nice letter. I didn't need to go through this process, but thought I would share a couple of links I had found in my research. I was ready to be denied so I spent some time looking.

http://www.obesityhelp.com/forums/insurance-help/

http://info.insure.com/health/claimdenial.html

Something to consider adding to the letter is a family history (if it applies) of things such as high blood pressure, diabetes, or depression. List family members and their problems. I did send a letter with my pre-d and included this info in the very beginning. Not sure if it will make a difference or not, but anything is worth a try.

Also, look up the posts of Mrs Sabre. I know she had to write an appeal letter. I truly hope you are approved quickly. Based on what you've shared here, it looks to me like you should definitely qualify. I hate the insurance game.....it's terrible. Hang in there and fight the fight. You can win this!! Good luck & keep us posted!!

[Mrs Husker 3]

3 Loves

Thank you soooo much. Reading some of the logs on obesityhelp gave me hope. I am also working on a list of my family medical history and my diet history. I have an appt with my PCP today at 9:30. Hope to get his help.

[Alexandra 55]

Good letter!

Just a typo that needs to be corrected: the word "excretion" probably should be "exertion" if you're talking about shortness of breath. Right? :cool:

You or your doctor should point out, too, that a BMI of 40 or above is the benchmark for determining the medical necessity of bariatric surgery. If they are declining you on that basis alone, they are making a medical determination that runs counter to all established medical criteria. (This is a sly way of saying you'll sue them, and they'd lose.)

If, on the other hand, they're just saying that you haven't yet established the medical necessity, that just means they're looking for more data. I mean, they CAN'T claim that with a BMI of 43 you are not medically qualified for bariatric surgery. What does their rejection letter actually say?

[Mrs Husker 3]

They said:

Benefits are not available for those services which have been

determined to be not medically necessary per physician review.

Therefore, no benefits are available for laparoscopic bypass surgery

(LAP band), as this has been determined to be not medically

necessary, as it does not meet medical policy criteria, as there is no

documentation of two years of medical management.

I saw my dr today, when I asked about the medical management part, he said, thats what you have been doing. I showed him a copy of my letter, he thinks it will work, and to let him know if it didn't and he would send one also. Wish he would send on now so I wouldn't have to wait.

All of this has me thinking, when the LB dr sent in for approval, didn't she point out any of my medical problems?

Well, got to go, I am doing a glucose(sp) test (might be able to add hyop glycimic (sp) to the list) and have to get back to the hospital in about 45 mins.

[Randi 0]

There's a couple of appeal letters posted at this thread: http://lapbandtalk.com/showthread.php?t=2527&page=2.

[Randi 0]

Barb,

Request to see what was submitted. You're definitley entitled. There may also be something in there that you can use in your appeal letter.

[3loves 0]

I kept in direct contact with the pre-d dept at my insurance company. I spoke to the same lady each time and asked her to specifically state EXACTLY what they needed and wording. My psychologist recommended me for surgery, but insurance required it to be written a certain way. It was re-written and faxed back to them. Silly, but we had to play the game.

Don't be afraid to speak directly to your insurance company and someone in that dept....not the rep answering the phone. Make sure you repeat back to them what they need so that everyone is perfectly clear on the requirements. I also got a rep involved at the corporate location for the company my DH worked for. They were an advocate for me and had the ability to give the green light if necessary since we were self-funded insurance.

Here is a link sharing some of my dealings with my insurance company: http://www.lapbandtalk.com/showthread.php?t=17107 It's kind of long, but maybe there is something there you will find helpful. Hang in there and play their game.....don't let them beat you. Sometimes I think insurance wants to see how dedicated a person is to getting this surgery and I bet some people do give up, which is music their ears.

[Mrs Husker 3]

I reposted this under a different thread

[RLittman 4]

I am not a happy camper right now. I have a BMI of 38.5 but was denied by Unicare because my co-morbidities are not severe enough. I have degenerative discs in my lower back, stress incontinence, borderline diabetes and high blood pressure, high cholesterol, family history of diabetes and high blood pressure. If I weighed 12 pounds more or if my medical conditions were worse then I would qualify. My doctor would like me to do a sleep study because she feels my insomnia is due to apnea, but it will likely cost me over $1000. Any thoughts?

[lisah25 3]

I am not a happy camper right now. I have a BMI of 38.5 but was denied by Unicare because my co-morbidities are not severe enough. I have degenerative discs in my lower back, stress incontinence, borderline diabetes and high blood pressure, high cholesterol, family history of diabetes and high blood pressure. If I weighed 12 pounds more or if my medical conditions were worse then I would qualify. My doctor would like me to do a sleep study because she feels my insomnia is due to apnea, but it will likely cost me over $1000. Any thoughts?

Would your insurance pay for the sleep study? Mine will, outside of any consideration of a band.

[Mrs Husker 3]

[ My doctor would like me to do a sleep study because she feels my insomnia is due to apnea, but it will likely cost me over $1000. Any thoughts?]

Get the sleep study done, but make sure that nothing is said about it being weight related. My insurance will not pay of anything (other than surgery) if it is weight related.