I need help with an appeals letter

[Rekeca 0]

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.

[Nancy Rivers 24]

Just google search "appeal health insurance" - there's quite a few hits along with some sample letters when I did the search. Hope it helps.

[Tiffykins 673]

Here's the links, I've had bookmarked:

http://www.obesityhelp.com/morbidobesity/information/wlsjourney/insurance+trouble.php

http://verticalsleevetalk.com/insurance-financing/1496-my-appeal-draft-w-references.html#post14133

http://vsgappeal.blogspot.com/2009/06/appeal-letter.html

http://verticalsleevetalk.com/pre-operation-vertical-sleeve-surgery-vsg-questions-answers/1751-unapproved-sleeve-ready-cry-2.html#post17480

http://thediaryofafatwoman.blogspot.com/2008/11/deny-deny-deny.html

(The lady above got hers approved)

[Tiffykins 673]

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.

I posted some links that I"ve had bookmarked for awhile on how to get approval. BUT, if you do not meet the requirements, you will have an uphill battle. My highest recommendation is to get a letter of support from your PCP/PCM that has managed your care for that time, get a new surgeon because it's denied after your initial appeal, you will need a peer to peer review, and if your surgeon is NOT willing to do that for you, then I personally would not allow him to cut on me, and get paid for it.

Here is a sample of a support letter for you PCP/PCM.

To Whom It May Concern:

This Letter is a formal request for approval for Bariatric Sleeve Gastrectomy, for my patient _____________D.O.B______.

__________ is Xfeet and X inches tall and weighs XXXpounds. Her body mass index (BMI) isXX. She has been diagnosed with morbid obesity (CPT code: 278.01), since ____. She is having significant adverse symptoms as a result of her obesity. She is having difficulty standing and exercising due to the significant impact of the excess weight on her body. She has difficulty performing any daily activities and in participating with her friends and family in recreational activities.

She has been diagnosed with ____________________. The effects of these conditions are severe, and can be life threatening. Co-morbidities have proven to be expensive to treat and sometimes incurable. Research has shown that weight loss is not only cost effective for the insurers, but for the patients as well.

_________________ has made numerous weight loss attempts, including:

• South Beach Diet
• Weight Watchers
• Curves
• Transformations medical weight loss
• Michael Thurmond
• Certified nutritionist consultations

Based on ____________�s medical history, it is highly recommended she undergo bariatric surgery. In my professional opinion, it is the only way to improve her health conditions and significantly improve her lifestyle. If you have any questions or concerns, please do not hesitate to contact our office.

Sincerely,

MD

[wishes 125]

Wow, Tiffykins, thank you so much for that great information. Just in case I am denied, I can't tell you how much I appreciate all this info.

[Rekeca 0]

Thanks for all of the wealth of information. I will be using it in writing my appeals letter.