Putting together my 2nd appeal

[DreamsOfSkinny 53]

So far I have a 7 page appeal letter with all of my documentation from previous denials and issues and then about 50 resources (each also printed and highlighted for info referencing). I am still being denied because I don't have a BMI of 40 for the last 5 years (even though my insurance summary plan description only states I need a diagnosis of morbid obesity from a physician for last 5 years -which I have- and standard for morbid obesity is Bmi of 40 OR 35 with 1 co-morbidity). The insurance has said there is specific language in my SPD that isn't even in there (I have copy and talked to employer and advocate) saying it has to be class III morbid obesity and a minimum of BmI of 40. I'm fighting this and hope with all of this package that someone will review it and see that I was denied 3 x's based on errors on UHC's side.

I also got 3 more letters from physicians treating my pseuddotumor cerebri in support of surgery. Sending off tomorrow

[gloriann 43]

Good luck on getting your approval. Be patient hun, i"m sending hugs ((())) your way. Keep us posted.

[oklafarmgal 31]

What insurance do you have? I know this is going to be a problem with me too. Good luck!

[oklafarmgal 31]

What insurance do you have? I know this is going to be a problem with me too. Good luck!

[Pookeyism 1,143]

Go ahead and research what your next step is should you be denied, and have it lined up...it sounds like your insurance is fighting you hard. Is your doctor being of any assistance? If not find one that will help you. If they are experienced enough to take your money and be trusted with this surgery, they should also be able to be a strong advocate with the insurance process.

Good luck.

[DreamsOfSkinny 53]

What insurance do you have? I know this is going to be a problem with me too. Good luck!

United healthcare

[DreamsOfSkinny 53]

Go ahead and research what your next step is should you be denied' date=' and have it lined up...it sounds like your insurance is fighting you hard. Is your doctor being of any assistance? If not find one that will help you. If they are experienced enough to take your money and be trusted with this surgery, they should also be able to be a strong advocate with the insurance process.

Good luck.[/quote']

They have helped and he's written a letter this time with the very specific wording the insurance is denying me for.... So we'll see if that helps. Next step is external appeal and I feel like I'd really just be re-sending the exact same package to them.

[oklafarmgal 31]

Oh yea, I think we have had this discussion before. Pookeyism is right. If they are smart enough to take your money and do your surgery, you would think they would be smart enough to get it past the insurance. I know that I am not going to fight with them too long before I go to Cancun. It's just so much cheaper and a whole lot less headache. And, I know that is exactly what UHC wants you to do. Know what I mean????? No cost to them.....

[DreamsOfSkinny 53]

Oh yea' date=' I think we have had this discussion before. Pookeyism is right. If they are smart enough to take your money and do your surgery, you would think they would be smart enough to get it past the insurance. I know that I am not going to fight with them too long before I go to Cancun. It's just so much cheaper and a whole lot less headache. And, I know that is exactly what UHC wants you to do. Know what I mean????? No cost to them.....[/quote']

Well I'm going to keep fighting it. I know they want you to give up. And yes, it definitely feels that way but I can't afford out of pocket and I really want my Dr. And any aftercare covered and him near by if there are any issues. The way UHC supervisors were talking, they all were like - just file a 2n level appeal- almost as if it would then have a better chance of being approved vs me fighting them on the pre-authorization, peer to peer, or 1st level appeal.... I'm really hoping and praying for this. I now have 10 pages typed and neatly organized stacks of references and previous documents of this entire journey. Whew! I just want an answer asap once I submit it lol Don't we all?!

[DreamsOfSkinny 53]

I was so excited yesterday! I called UHC to again ask where exactly this language came from after speaking with Lindstrom law telling me that ins. Companies can have "behind the scenes" policies and guidelines they don't always share with patients. I talked to a supervisor that was SO nice! He even gave me his FULL name AND DIRECT telephone number. I just had to thank him again for helping me look into this before I submit my 2nd level appeal. He totally agreed with me that this language is nowhere and that I should be approved based on meeting the criteria in my Summary Plan Description. I truly hope he can help shed some light on this.

The consumer affairs person from corporate no longer wants to return my calls. She sent me a letter saying the case is closed for her trying to find out where the language came from for a BMI of 40 for past 5 years. It simply said that this is what it is, and I'd need to show BMI of 40 for last 5 years to be approved. Still no explanation of where this language is coming from. That was no help.

My advocate from work is having a conference call with my employer on Monday along with her boss to see where this language is coming from and why if the SPD has no definition of how they define "morbid obesity", how am I being denied? My SPD only states- must have a BMI of 40. It doesn't say "had" as in past tense for the past 5 years nor does it give any other details of this minimum BMI applies to. On a separate line it states - needs diagnosis from a physician of morbid obesity for 5 years.

I have now asked my Dr. To specifically write the ICD-9 code for this an state this is for the past 5 years. I feel now I should be approved. I've met all 4 criteria but insurance seems to to be wanting to apply the first criteria having a minimum BMI of 40 for the second criteria - morbidly obese for 5 years. Ughhh!! My insurance should have a clearly defined definition!! I think I found a place for improvement for 2013 policy!

[DreamsOfSkinny 53]

Well I've left voicemails for the consumer affairs person I talked to at UHC and the new representative past 2 business days with no response. I'm sure my file now reads - crazy b***h keeps calling. Don't call back lol!!!

But I now have finished my appeal letter. 14 pages long plus tons of references. It's an entire package I have to mail off tomorrow - certified that is. I found out that the insurance has violated both ERISA and the Protection and Affordable Care Act, so I kindly put each code and section in my letter as well

My employer is now siding with the insurance company (although it is self-insured) and says that they are adding language to my SPD for clarity. Wait wait wait. According to both aforementioned acts PLUS several court proceedings, if I can prove I relied on my SPD to base my eligibility on then that should be final say AND the employer can only change language with a 60 day heads up to employees. Sneaky bastards.

Here we go again. Under ERISA I should hear a reply within 15 calendar days! NOT business. I'll once again call every other day to check status. Now I need to lose my 10 lbs so when they approve me I can have this darn surgery already.

[oklafarmgal 31]

Good for you! ! I hate dealing with insurance. Seems like they always win. Go get 'em girl! !

[SerendipityHappens 1,594]

HOW FRUSTRATING!!! Reading stories like this makes me actually relieved that I was not covered for WLS by insurance.

[DreamsOfSkinny 53]

I called the Department of labor today They said if I'm still denied after this level to contact them again and they'll get involved with my employer. Based on the insurance company denying me for language they say is in my SPD --but actually isn't-- and for my employer nor UHC being able to provide me documentation of where this language is written.

I'd hate to have to go to that level but my employer is leaving me no choice! I also found last night a couple of court cases - one with Uhc self-funded plan for denying someone for obesity surgery. Her plan stated the EXACT same criteria. I included in appeal letter and stated UHC has shown in this case that they never said she needed to have a bmI of 40 for 5 years.

Prayers appreciated and good thoughts!! I also found out that by ERISA standards and my SPD UhC has to give me answer within 15 calendar days.

[DreamsOfSkinny 53]

Good for you! ! I hate dealing with insurance. Seems like they always win. Go get 'em girl! !

Ty!! After this I think I can put together an e-book for others going through appeal process.