Denied Again

sarcar · September 13, 2005

Well my insurance says they pay for the morbidly obese to have lap band but I'm beginning to wonder. They first said all I had to do was go on a 3-month diet that I would be on after the surgery. I did and we covered all the basis -

nutritionist and md supervised. So they sent in the letter but the PA signed for it because Texas accepts PA in the same manner that it accepts MDs. That was denied and they told the doctor's it had to have the MD signature. The person told the surgeons staff that if they get the letter with the

nutritionist, pa and md signature it would be approved. Wrong - denied not medically necessary.

Does anybody have a well written appeal letter? Nobody will tell us why it is not medically necessary and I have met 100% of the the qualifications that they sent me. So I'm not sure what their deal is but I need to appeal and I want to make sure I do this right the first time around.

Carolyn

Thinjen · September 13, 2005

My heart goes out to you. I'm facing the same thing. "Not medically necessary." I guess they'd rather pay for the diabetes and heart bypass that I'll need in 10 years. I wonder which is cheaper? What gets me (and I'm sure you too) is that I've had 2 doctors that have examined me and said yes. And some insurance clerk that has never laid eyes on me saying "not medically necessary." Maybe I should go sit on her(if she survived) and see if she changes her mind. I haven't written an appeal letter yet. Let me know if you find out anything.

Alexandra · September 13, 2005

Carolyn, to fight the "not medically necessary" determination your doctor will have to get involved. That's a case that only a medical person can make. It's possible that your file simply didn't include enough evidence (like a sleep study or something?) or that you are indeed borderline and that's the hangup.

Try talking to your doctor and asking him to get specific details from the carrier about why it's not being accepted as medically necessary. He should have a provider-relations phone number he can call where he can speak with medical staff. You will likely not be able to get access to the same people and the customer-service reps you can speak with don't know jack.

Good luck!!