So I finally got my letter back from HealthNet today. They denied the request for surgery and basically said they would need more information - specifically regarding "any history of anemia, inflammatory bowel disease, Chron's disease, surgery history, celiac disease, ulcerative colitis, and medication history (specifically anti imflammatories).

I guess this is not a flat out denial but I'm still sort of in shock. I have a 54 BMI, gout, high blood pressure, arthritis and have been overweight/obese since I was about eight years old. I know I'm not as bad off as some people....but I thought I was pretty much a poster child for who should get this surgery. The surgeon and coordinator at his office both said I was a total shoe in and that they haven't had any problems with Health Net. It's definitely covered and I made sure that my employer did not have an exclusion for it.

So any ideas on what to do next? I'm not sure how the appeal process works and I haven't had any of the bowel issues (Chron's, celiac, IBS, etc) that they are mentioning. The only thing close is Gout and I have to occaisonally take some strong NSAIDS when that flares up (like Indocin).

Thanks for any ideas.

Peer to Peer review with a letter of support from your PCP or whichever doctor manages your use of NSAIDS.

A lot of insurance companies automatically deny and hope that you will back off. DON'T. I have had to write many letters when being denied for surgery (not this, because it is excluded) but, for instance, my son had heart surgery and had an extra tooth in the roof of his mouth and they didn't want to pay for him to be under general anesthesia, they wanted him tied to a papoose board while they pulled a tooth, Um, no, he was not even three years old. I wrote a pretty detailed letter, you have to put in 'catch phrases' that they are looking for, 'history of arthritis with a need for prescribed Indocin and daily over the counter nsaids (hey, they don't know you don't take these, as they are not prescribed), You shouldn't have to have both stomach problems and a need for these meds, so, you should be alright with just having that. It doesn't have to be a 'book' my letters are usually about one page long, just state that you realize that arthritis normally worsens with age, and that since you already take XYZ milligrams of blah blah, you do not want to find yourself in a position of needing increased dosages as you age and finding that you cannot alleviate your pain due to not having the recommended surgery for your pre-existing arthritis, blah blah. I've usually gotten an approval within a week once I've submitted letters. LIke I said, they are counting on people giving up, DON'T!!!