Need help writing an appeal letter to get a Approved Referral

[BGrundee 61]

Hi Everyone

I have Aetna insurance with HealthCare Partners and having issues getting a an approved referral just to go to a bariatric surgeon. My PCP said I wouldn't have a problem but unfortunately I am. I am 4'11/193 lbs with a BMI of 38.7 with health problems such as joint pain especially in ankles, stress incontinency, etc. My whole livihood is going down the drain, and believe me I work out 4 times a week just to make sure I do not gain anymore weight as I'm pushing into 200 lbs and it's scary.

Thanks

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[Noworneverthin 59]

Usually you need 2 health issues that fall into the categories of Heart disease, diabetes, arthritis, sleep apnea if your bmi is below 40.

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[Noworneverthin 59]

I didnt qualify because even though I have diabetes, arthritis, high blood pressure, my bmi is under 35, its 34, so I just paid for it myself. $18,000 gastric sleeve surgery date Aug 9

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[Noworneverthin 59]

High bp is another qualifying factor.

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[heycrystal2052 430]

I was so heavy (BMI 68) , I met all of my employers (BCBS) criteria w/out needing to have additional issues. If I may ask, do you have a group policy or Marketplace?

[BGrundee 61]

I read someone on here wrote a letter to help get them approved and it was well received...I'm hoping to write a letter

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[heycrystal2052 430]

I know w/ us, we will deny you several times , after that, you can not submit a PA for a year or until a policy change. Make sure you're aware of how many times a PA can be submitted on your behalf, I'd hate to see you run into that.

[Sosewsue61 3,185]

You need actual comorbidities - high blood pressure, etc. If you can work out 4x week then your ankles are tolerating that. Do you have sleep apnea or any other issues? If you were 201lbs your bmi would be 40 and most insurances cover people at 40 bmi.

[dstgirl11 22]

I have BCBS of Alabama and had a 40 bmi and two comorbilities (hp and sleep apnea). I was still denied. So, I had to get a letter from my PCP and send in pictures. After about six weeks of no replys, I started a one-on-one chat sessions (2 total). After my last chat session, I was approved. Hope this help.

[BGrundee 61]

You need actual comorbidities - high blood pressure, etc. If you can work out 4x week then your ankles are tolerating that. Do you have sleep apnea or any other issues? If you were 201lbs your bmi would be 40 and most insurances cover people at 40 bmi.

I spin on a bike to help stay off my ankles but still allow me to peddle since I'm sitting on a seat and do pilates on a reformer machine to help with abdominal/back strengthening. I'm pretty big at 193 lbs and 4'11. I'm doing what I can to maintain and not go over. Seriously trying get up every morning my ankles are hurting like hell and even after a short walk I'm done. I don't want to NOT do anything for myself

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[BGrundee 61]

I was so heavy (BMI 68) , I met all of my employers (BCBS) criteria w/out needing to have additional issues. If I may ask, do you have a group policy or Marketplace?

I have a group policy. I just talked to insurance and have to write an appeal. I'm going to submit a years worth of exercise history, which thank god I have because my studio logs every class for you and have a letter from my doctor. I will be doing my sleep study in two weeks...

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[OutsideMatchInside 10,166]

Honestly, the right program will know how to get you approved. I chose the program I chose because they had a streamlined system and know how to work with insurance. If your program can't get you approved, choose a different one.

[BGrundee 61]

10 hours ago, heycrystal2052 said:

I know w/ us, we will deny you several times , after that, you can not submit a PA for a year or until a policy change. Make sure you're aware of how many times a PA can be submitted on your behalf, I'd hate to see you run into that.

Hi Crystal,

I have a group policy and weight loss surgery is covered 80%. I need tips and wise advise on appealing. I'm only 1.3 points from being 40 BMI. I want to write my insurance and tell my story. I wish there was a template I can follow so I know how to write my truths as professionally as possible without being all over the place.

Im going to go see my PCP on Monday to discuss because all she wrote on the notes was that I snore. She didn't write I have stress incontinence due to all this extra weight and joint pain in my ankles...Especially my feet. The heels and balls of my feet hurt so bad even with sole pads.

Do you work for insurance and why would you deny someone several times? Just asking because any and all knowledge helps so much.

Kind regards

Becky

[BGrundee 61]

9 hours ago, OutsideMatchInside said:

Honestly, the right program will know how to get you approved. I chose the program I chose because they had a streamlined system and know how to work with insurance. If your program can't get you approved, choose a different one.

Hi,

Theres only a few surgeries that are approved from Aetna and my PCP felt like doing the surgery was my best options. She told me I would have the best results doing surgery to reset my body as pills and exercise are not really impacting me as much. Right now, when I work out (Spin cycling or Pilates) Im doing it to keep my back and stomach strong as much as possible also to keep me from gaining any further weight. Its the only defense I have right now and its a real fight. My body will not shed 1 lb. I know girls that eat right, work out, and sheepishly shed weight like nothing. For me, I have to work 3x times harder to make sure I dont gain anymore and i'f im lucky maintain my current weight for the month. I can't run cause my feet, ankles, and joints hurt but I can spin for a solid hour since Im sitting on a bike and will sweat a lake but just cant slim down for the life of me.

[dstgirl11 22]

11 hours ago, BGrundee said:

I wish there was a template I can follow so I know how to write my truths as professionally as possible without being all over the place.

If you go to www.obesitycoverage.com and look across the top, click on the heading Insurance Coverage. Then, click scroll down until you reach the seventh heading under sample letter of appeals. Hope this helps.