Need help with an appeal

Nan1109 · January 6, 2009

I had the same problem. After all my info was sent to BCBS, I was denied because my BMI was 39 with no other co-morbidities. I came on here and found SuzanneG, who offerred her letters of appeal. I accepted and rewrote them in my own words. I explained that even though I don't have diabetes or high blood pressure, I DO have osteoarthritis which affects my hips and knees. I also mentioned that all my doctors have said that without wls, I WILL develop these conditions. But I think the most important part of my appeal letter was when I described the emotional impact my weight has had on myself and my family. I cried while writing the letter. Without Suzanne's help, I never would have known what to write. I was approved. My letter from BCBS said that since my BMI, when I started my journey 6 months earler, was 40, they would approve me! I think it was just an excuse, but I really didn't care why, I was approved. I had my surgery on 12/19. When my dr's office called, two days before my scheduled surgery, to say I was denied, I was in shock!! I'd read about it happening, but never thought it would happen to me. If you would like a copy of my letter, please let me know. Better yet, get Suzanne's; they're amazing! DO NOT GIVE UP - you will be approved!!

Walter · January 9, 2009

Before appealing on your own or having your surgeon appeal remember that if you are getting an Allergan LAP-BAND® our office works in conjunction with you and your surgeon's office to handle LAP-BAND appeals at no cost to you. You get the benefit of our 13 years of experience handling bariatric surgery cases (not to mention any personal tidbits I can offer having had an open gastric bypass in 1994 followed by a LAP-BAND® in 2003!) You should contact your surgeon about getting an Appeals Program application before doing anything else since we can only take these cases on at the time of the first denial.....in case you're wondering, our success rate in 2008 with this program exceeded 92%. Hopefully we can help you or others in your position overturn that denial. Good luck.

Mrsace13 · January 10, 2009

Walter, thank you. They did a peer to peer and then sent me the package to do my letter.

Nan, I HAVE HER LETTERS, THEY ARE PERFECT!! She emailed them to me and I am doing the same thing, using hers as a shell letter and filling in my own info and yes, crying as I am doing so. I just pray my end result is the same as yours.

Nan1109 · January 11, 2009

Teresa, I also got my letters from my pcp and rheumatologist, but I know in my heart that it was MY letter that made the difference! Good luck; PLEASE let me know how you make out! I will be thinking of you! Nancy

mroseharvey · January 12, 2009

Can I still appeal through the Allergan program if I was denied by my insurance company and than I scheduled my surgery and paid cash? Can I file for the appeal and possibly get some reimbursement. I was so frustrated with the insurance company and I was so upset I just kept my surgery date and financed it. Thank you.