Denied and not sure what to do

[Amanda1038 1]

I started the goal to weight loss surgery almost 3 months ago. Everything was rolling along smoothly. Me and my surgeon was on the same page I lost almost 40 pounds on the diet before surgery proving I can and will keep the life style. The date was set for November the 4th and we thought everything was checked and crossed. I did everything they asked of me and my dr said I was the perfect candidate for surgery. 2 days before surgery my Insurance send my doctor a denial letter. I will attach the letter to the post. Now I want to appeal but I'm confused on how I do this. My Insurance said to send appeal letter to them. What should I put in my appeal letter I would appreciate all the help and suggestions.

Edited November 12, 2015 by Amanda1038

[Ashlegal 525]

Did they explain the reason for the denial?

[Tssiemer1 549]

They are saying it's not medically necessary and something about your mental health is a problem. And that you're not properly educated on the procedure due to lack of documentation.

Call your surgeons office.

Edited November 12, 2015 by Tssiemer1

[Amanda1038 1]

The denial letter is a bit confusing but if I'm reading it right it was on grounds of depression and having acid reflux disease. Both thing I made clear in the beginning to the whole bariatric team that I have been seeing. I have had depression for years but it's under control with medicine. My dr did not see a reason why it would be denied.

[Amanda1038 1]

I went back to my dr yesterday. He seems to think its the way The results of the Psych evaluation was worded. The last part of that letter about not being educated is also confusing because I went to the seminar and I am very much educated on what the surgery will do and what the lifestyle change will be after. So this is why it is confusing

[Inner Surfer Girl 12,015]

Your surgeon's office should be able to help you with an appeal. Maybe they are just missing some documentation. Did you get a psych clearance?

Best of luck.

[Amanda1038 1]

The psych clearance was worded that I did pass but there were signs of severe depression. That could counter react the results of the surgery. This is why I am confused. My insurance is saying I need to send an appeal but my surgeon says to make an appointment with the psychologist. As to be medical necessity I have done everything on that list except Counseling. So do I make a appointment and do the appeal or do one before the other?

[The Candidate 3,215]

I also think you should get together with your surgeon's office and discuss exactly what is needed to appeal your denial. I sure hope things work out for you! Keep us updated.

[Amanda1038 1]

Thank you for the replays. I will call my dr again and see if he has advice this is just confusing as hell right now. I will keep y'all updated

[TristanNicole 169]

Yeah I'm sure your doctors office got the same letter you did for the reason for denial. What I understand from it is that there was no documentation that you had been treated for GERD and the Psych eval must have been worded in a way that you weren't ready for the surgery. I think you should do both, make an appt with the Psych to get a re evaluation and let them know what you are trying to accomplish so they can hopefully focus the visit on that, and work with your surgeons office to get an appeal going.

[Inner Surfer Girl 12,015]

The psych clearance was worded that I did pass but there were signs of severe depression. That could counter react the results of the surgery. This is why I am confused. My insurance is saying I need to send an appeal but my surgeon says to make an appointment with the psychologist. As to be medical necessity I have done everything on that list except Counseling. So do I make a appointment and do the appeal or do one before the other?

Make the appointment with the Psych. This sounds like what you will need to complete your appeal. The Psych can determine what you need by way of counseling to complete that requirement.

Best of luck.

[Djmohr 6,965]

I agree with @@TristanNicole, I would do both immediately.

Once you are in counseling and working closely with your doctors office then file the appeal and ask your surgeon to do a peer to peer review with your insurance company if necessary.

Don't lose faith, keep pushing through and remain as patient as you can. It takes a while to jump through the hoops but it is worth it in the end.

Keep your head up! You will get through this and come out on the other side if you follow all the required steps.

Good luck!

[halalo 13]

The psych clearance was worded that I did pass but there were signs of severe depression. That could counter react the results of the surgery. This is why I am confused. My insurance is saying I need to send an appeal but my surgeon says to make an appointment with the psychologist. As to be medical necessity I have done everything on that list except Counseling. So do I make a appointment and do the appeal or do one before the other?

Don't lose faith. Do everything your surgeon asked you for and they will fight and appeal for your case. They do this for living!