:think I got a rejection letter from the insurance today! Can I just say- They stink!!! I actually have some much stronger adjectives to describe them but I will spare all of you the cursing.

Our reviev determined that the denied services(Lap band) requested are NOT MEDICALLY NECESSARY based on the following:

There is no documentation of 12 continuous months of medically supervised weight loss program that includes nutritional therapy, behavior modification, supervised increase in activity, pharmacologic therapy-unless contraindicated-and maintenance support. This 12 month program must have been in the last 24 months. Programs such as weight watchers or Jenny Craig are not considered medically supervised weight-loss programs.

Anyways-I am upset to say the least. I have been through so much to try to get approved. How can they say it's not Med. necessary? With all of my medical problems, I am in the dr.s office atleast 2-3 times a month! Medical equipment for sleep apnea(which is probably due to weight!) Medications for depression, anxiety, migrains, etc...... Don't they understand that if I lose weight-many of these problems will go away?! I have so many thoughts and frustrations going through my head right now! This surgery has been the only source of hope that I have had that I might be able to actually live a normal life. I am trying not to have a "melt down" but I just feel like my rug between hope and hopelessness has just been yanked out from under me! What do I do now?

Lauri, unfortunately, the insurance company only wants the facts. They're not interested in you as a person. Dollars and cents are what get their attention. Your letter needs to be no more than one page in length and clearly state your case. Please ask Alexandra to help you. She works with insurance and knows what is needed. Here's a rough draft (using your available information):

Date

Re: Denial Letter #, dated

Dear Medical Review Department:

Recently you sent me a letter denying weight loss surgery. I am appealing that decision and ask that you send me the proper forms and all information necessary for me to follow your appeals process. Please advise your reasons for the denial and include copies of any documentations you used to make this decision. Also, please include the correct address to mail my appeal to.

Sincerely,

Lauri J.

Insurance Denial Letter #, date

SS#

Insurance Card #

address

home phone #

e-mail address

Lauri, right now, all you are dong is advising the insurance company that you plan to appeal their decision. You do not have to state your case yet. After they send you the proper forms, then be sure you follow their "Appeals Process" to the "t". Keep full copies of everything, document when they were sent, and to what address, and who's attention (if you can get a name).

Once you get the proper appeals procedure forms from your insurance company, then you can compose your Appeals Letter. Clearly state the facts, don't get emotional, include any documentation that supports your stand. Try to keep it short and to the point.

Rough Draft (Appeals Letter)

Date

Ins. Co. Name

Medical Review Department

RE: Denial #, dated

Dear Sirs/Madams,

I am appealing your previous decision to deny me weight loss surgery. My name is Lauri J. I am thirty-five years old and am morbidly obese. Dr. Cribbons at Plano Medical Center calculated my current BMI as 43.8 I have struggled with my weight for 27 years and I am losing the battle. I have sleep apnea, intense pain in my knees, hips, and back, high cholesterol, constant fatigue and shortness of breath, anxiety, depression, and high blood pressure. I battle daily with low self-esteem, societal rejection and prejudice, lesser work and income opportunities, marital, familial, social, and sexual problems - all directly related to my obesity.

My mother (due to her morbid obesity) has been disabled since her forties. She has had both knees replaced, suffers from high blood pressure, and extreme depression. She currently needs both knees replaced. Heart disease and diabetes run in my family.

I have spent countless amounts of time, money, and effort on numerous diets, low-calorie/low carbohydrate foods and drinks, exercise programs, and diet pills. These offered temporary relief, but have created a vicious cycle - lose the weight, only to regain more each time.

Obesity is a major risk factor for serious medical conditions such as:

Type 2 diabetes, Hypertension, Heart Disease, Stroke, Sleep Apnea, Respiratory problems, Cancer, Osteoarthritis, Joint pain. According to the National Institutes of Health, Morbid Obesity Surgery is the best option for people who are morbidly obese and cannot lose weight by traditional means or who suffer from serious obesity-related health problems.

To deny me Weight Loss Surgery now will only cause my health problems to escalate, meaning much greater medical expenses later - for added prescriptions, tests, hospitalizations, surgeries, disabilities - as my health declines. Joint replacements, open heart surgery, strokes, cancer, and long-term rehabilitation are just a few very real possibilities. These increasing health care costs will be shared by my health insurance company and myself.

Granting me Weight Loss Surgery will immediately improve my physical and mental health. Many of my health problems will be drastically reduced and in most cases - eliminated entirely. My prescription medications will drop. I will be able to get a full night's sleep without the c-pap machine. The serious health concerns listed above will cease to exist for me. Better health means less visits to the doctors, less prescription medications, less hospitalizations, less missed work days, more productivity, untold savings in medical costs.

I want to live!. This weight has such a negative impact on the quality of my life and is shortening the quantity of my life with each passing day. I have four beautiful children that need their mother to be here for them as they grow up.

I am asking you to carefully review my appeal and the documentation from my doctors and therapists validating the necessity of Weight Loss Surgery. Please grant that I may have this surgery and can begin living a healthier, happier life as soon as possible. Regaining my health means we all win!

Most Sincerely,

Lauri J.

Lauri, if you decide to use this letter, you need to finetune it for accuracy. I'm not sure what your actual health problems are. I tried to use all the info. you had, but it could probably be reduced down some more. The main thing, is to get their appeals procedure and follow every little step. Appeals do work. I did it. Best of luck to you!

Lauri, I'm sorry I haven't had a chance to take a look at this yet--last night we went out shopping and I didn't get five minutes to sit down and read it. I'll try to get to it before lunchtime today.

Just quickly: Marie is right--you don't want to get emotional in your letter. Try to read it with the most critical eye you can, think MEDICAL ISSUES and try to stay away from words that describe feelings. The carrier doesn't care if you're happy, they only care that their actions can't lead to their getting sued down the road. Address the specific issues they mention in the denial letter (I can't remember what they were right now, sorry).

Gotta run, I'll be back later!

Thank you both! I will work on it.

Hi Lauri,

Now that I look at the first post again, I think your best bet with this specific issue is to have your doctor write a letter. The carrier is simply saying that you haven't fulfilled their requirement of a 12-month supervised weight-loss program in the last 24 months. They're allowed to set that bar in terms of assessing who is a good candidate for surgery, since they want to discourage people from going straight for the knife without trying other means first. That makes sense.

So if you've been seeing your doctor over any period of time for your weight issues, she can write an appeal letter stating that you've been under her care for XX years following a program she devised. If you haven't been doing this, then you may have no option but to start immediately and get that clock started.

This is not a major-league, slammed-door denial. They did not say they don't cover the band or that you are not a good candidate for it. They're just saying you haven't jumped through all of their hoops yet, and are very helpfully illustrating what hoop you have missed. I think you're in good shape, actually, and it's just going to be a matter of time.

I agree with Marie and Alex. It's good that you wrote the letter since writing is therapeutic, and getting the words on paper will help you put things in perspective. But keep the emotions and feelings out. Just the facts, M'am, nothin' but the facts. Put the strongest argument at the beginning and keep it one page if possible.

Do you use Word or WordPerfect? I have both. PM me your e-mail address so I can attach my letter and forward it via e-mail.