Jump to content
×
Are you looking for the BariatricPal Store? Go now!

Need help writing an appeal letter to get a Approved Referral



Recommended Posts

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

Sent from my SM-N910T using BariatricPal mobile app

Share this post


Link to post
Share on other sites

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

Sent from my LGMS550 using BariatricPal mobile app

Share this post


Link to post
Share on other sites

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

Sent from my LGMS550 using BariatricPal mobile app

Share this post


Link to post
Share on other sites

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?

Share this post


Link to post
Share on other sites

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

Sent from my SM-N910T using BariatricPal mobile app

Share this post


Link to post
Share on other sites

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.

Share this post


Link to post
Share on other sites

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.

Share this post


Link to post
Share on other sites

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.

Share this post


Link to post
Share on other sites

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

Sent from my SM-N910T using BariatricPal mobile app

Share this post


Link to post
Share on other sites

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...

Sent from my SM-N910T using BariatricPal mobile app

Share this post


Link to post
Share on other sites

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.

Share this post


Link to post
Share on other sites

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

Share this post


Link to post
Share on other sites

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.

Share this post


Link to post
Share on other sites

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.

Share this post


Link to post
Share on other sites

Create an account or sign in to comment

You need to be a member in order to leave a comment

Create an account

Sign up for a new account in our community. It's easy!

Register a new account

Sign in

Already have an account? Sign in here.

Sign In Now

  • Trending Products

  • Trending Topics

  • Recent Status Updates

    • vsg.with.sharon

      Hey everyone!
      I’m new here! Looking for some friends! 🥰
      · 0 replies
      1. This update has no replies.
    • LeighaTR

      Four days post surgery. I am sipping as fast as I can and getting NO WHERE near the goal of 60 - 80 grams of protein or the 64 oz of liquids. I just feel FULL. I don't know if it can still be the gas build up (I would think by now that would be gone) but it is a struggle to drink. And so far I have not had the nausea or spasms and don't want to wander into that territory by pushing too hard with liquids. I about passed out today as it was my most "strenuous" day. Went from second story to basement for shower and I was sure I was going to pass out. Looking back on my last few days I have had a total of less than 1000 calories. Am I just not getting enough nourishment in me? Once again a friday where I can't get ahold of the doc until Monday rolls back around so I am hoping maybe someone here has some experience on how to keep energy going. I do have fibromyalgia too and that may be where some added fatigue comes into play. How did you all fair with the goals the week after surgery?
      · 0 replies
      1. This update has no replies.
    • Doughgurl

      2 days until I fly out to San Diego to have my Bypass Surg. in Tiajuana Mexico. Not gonna lie, the nerves are starting to surface. I don't fear the surgery itself, or the fact that I'm traveling alone, but its the aftermath that I'm stressing about the most, after this 8 week wait. I'm excited to finally be here, but I am really dreading the post surgical chapter. I know its going to be tough, real tough and I think I'm just in my head to much now that the day i here. Wish me luck, Hopefully I'm one of the lucky ones, and everything goes smoothly. Cant wait to give an exciting update,. If there is anyone else have a June bypass or even a recent one, Id love to have someone to compare war stories with. Also, anyone near San Antonio Tx? See ya soon with the future me. 💜
      · 3 replies
      1. Phil Penn

        Good Luck this procedure is well worth it I am down to 249.6 lb please continue with the process..

      2. Selina333

        I'm in Houston so kind of near you and had the sleeve in Dec. Down 61 lbs. Feeling better. Was definitely worth it. I hope the everything is going well for you. Update us when you can!

      3. Doughgurl

        I am back home after my bypass surgery in Tiajuana. I'm post op day 4. Everything went great! I guess I'm one of the lucky ones who have not encountered much pain at all, no nausea thus far and I'm having no problem keeping down broths and water. Thank you for your well wishes. I cant wait to keep up this journey and have a chance at better health and simply better quality of life. I know there will be bumps in the road ahead, and everything won't be peaches and cream, but at least I have a great start so far. 😍

    • LeighaTR

      I am new here today... and only two weeks out from my sleeve surgery on the 23rd. I am amazed I have kept my calories down to 467 today so far... that leaves me almost 750 left for dinner and maybe a snack. This is going to be tough for two weeks... but I have to believe I can do it!
      · 0 replies
      1. This update has no replies.
    • Doughgurl

      Hey everyone. I'm new here so I thought I should introduce myself. I am 53y/o and am scheduled for Gastric Bypass on June 25th, 2025. I'm located in San Antonio, Texas. I will be having my surgery in Tiajuana Mexico. I've wanted this for years, but I always had insurance where bariatric procedures were excluded. Finally I am able to afford to pay out of pocket.  I can't wait to get started, and I hope I'm prepared for the initial period of "hell". I know what I have signed up for, but I'm sure the good to come will out way the temporary period of discomfort and feelings of regret. I'd love to find people to talk to who have been through the same procedure or experience before. So I look forward to meeting you all. Hope you have a great week!
      · 2 replies
      1. Selina333

        I'm so happy for you! You are about to change your life. I was so glad to get the sleeve done in Dec. I didn't have feelings of regret overall. And I'm down almost 60 lbs. I do feel a little sad at restaurants. I can barely eat half a kid's meal. I get adults meals often because kid ones don't have the same offerings at times. Then I feel obligated to eat on that until it's gone and that can be days. So the restaurant thing isn't great for me. All the rest is fine by me! I love feeling full with very little. I do wish I could drink when eating. And will sip at the end. Just a strong habit to stop. But I'm working on it! You will do fine! Just keep focused on your desire to be different. Not better or worse. But different. I am happy both ways but my low back doesn't like me that heavy. So I listened (also my feet!). LOL! Update us on your journey! I'm not far from you. I'm in Houston. Good luck and I hope it all goes smoothly! Would love to see pics of the town you go to for this. I've never been there. Neat you will be traveling for this! Enjoy the journey. Take it one day at a time. Sometimes a few hours at a time. Follow all recommendations as best you can. 💗

      2. Doughgurl

        Thank you so much for your well wishes. I am hoping that everything goes easy for me as well. We don't eat out much as it is, so it wont be too bad in that department. Thankfully. Also, I hear you regarding your back and feet!! I'd like to add knees to the list. Killing me as we speak! I'm only 5' so the weight has to go. Too short to carry all this weight. Menopause really did a doosey on me. (😶lol) My daughter also lives in Houston. with her Husband and my 5 grand-littles. I grew up in Beaumont, so I know Houston well, I will be sure to keep in touch and update you on my journey. I may need some advice in the future, or just motivation. Thank You so much for reaching out, I was hoping to connect with someone in the community. I really appreciate it. 💜

  • Recent Topics

  • Hot Products

  • Sign Up For
    Our Newsletter

    Follow us for the latest news
    and special product offers!
  • Together, we have lost...
      lbs

    PatchAid Vitamin Patches

    ×