Need help writing an appeal letter to get a Approved Referral

[BGrundee 61]

22 minutes ago, dstgirl11 said:

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.

Thank you so much! *hug* I greatly appreciate it. Please pray for me my insurance has a change in heart...Otherwise i will most likely have to go to Tijuana!

[dstgirl11 22]

Just when I was thinking of self-pay, my approval came through. If I can help in any way, please do not hesitate to ask. Best wishes.

[Mrsburk525 13]

My surgeon did a peer to peer before Aetna would approve me. I have a history of Barretts esophagus, sleep apnea, atrial fibrillation & SVT. The Barretts esophagus is what got me approved. My surgeon told me that Aetna is going up from the 5000 copay to a 10000 copay September 1st.

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[heycrystal2052 430]

On 7/21/2017 at 11:43 PM, BGrundee said:

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

I'm sorry, I'm just getting back to you on this. The weekend has been a busy one, but the responses are great. I can say, based on what you mentioned, that's not enough for an instant approval. Did your Dr., request a P2P? Sometimes, w/ additional documentation, a P2P (Peer to Peer) can be successful, although it is rare to have our denial overturned. Some policies will allow our denial to be overturned w/ the outside Medical Director. W/ your appeal, make sure you are diagnosed w/ these ailments and not just "having problems", w/ certain ailments. Have you been diagnosed and if so, were you diagnosed by a specialist or just a PCP? Over the last three years, how has your weight been and was it noted? To be honest, you're on the fence here, I can't find a reason to approve your PA. There has to be more. As someone noted before, most Dr's, know what needs to be done to get an approval. Not saying they'll lie, they just know what needs to be focused on and they go for those key components.

[BGrundee 61]

1 hour ago, heycrystal2052 said:

erI'm sorry, I'm just getting back to you on this. The weekend has been a busy one, but the responses are great. I can say, based on what you mentioned, that's not enough for an instant approval. Did your Dr., request a P2P? Sometimes, w/ additional documentation, a P2P (Peer to Peer) can be successful, although it is rare to have our denial overturned. Some policies will allow our denial to be overturned w/ the outside Medical Director. W/ your appeal, make sure you are diagnosed w/ these ailments and not just "having problems", w/ certain ailments. Have you been diagnosed and if so, were you diagnosed by a specialist or just a PCP? Over the last three years, how has your weight been and was it noted? To be honest, you're on the fence here, I can't find a reason to approve your PA. There has to be more. As someone noted before, most Dr's, know what needs to be done to get an approval. Not saying they'll lie, they just know what needs to be focused on and they go for those key components.

Hi Crystal,

Thanks for even getting back to me. I greatly appreciate it. My spoke to 2 different insurance agents and both told me to appeal and write a letter explaining how the surgery would benefit me, include I have tried on my end other options (exercise, pills), include a doctors letter that even though only shy 1.3 points (4-5 lbs) to get approved it is doctors orders for surgery. In March I was 202 lbs and would have been at 41 BMI, but I really wanted to give it a try myself to lose weight. I only lost 7 lbs between March and July. I also have on record trying Belvique and Contrave but had little success. I know 193/194 sounds alot less than many people on here but when you 4'11 its like alot of weight for a short person with a small frame. I have to exercise harder than skinny girls to maintain myself being at 193/194. Surgery is the best option to have successful results.

If all else fails, I will just make my way to Tijuana because its the same amount of money I would have to pay out of pocket and TJ is 2.5 hour drive from me...

Thanks

Becky

[BGrundee 61]

On 7/22/2017 at 11:40 AM, Mrsburk525 said:

My surgeon did a peer to peer before Aetna would approve me. I have a history of Barretts esophagus, sleep apnea, atrial fibrillation & SVT. The Barretts esophagus is what got me approved. My surgeon told me that Aetna is going up from the 5000 copay to a 10000 copay September 1st.

Sent from my SM-G928V using BariatricPal mobile app

MY PCP doesn't do P2P, she said she could only write a letter or doctor's note for me as she is not the surgeon. The first hurdle is getting Aetna to even allow me to see a Bariatric Surgeon. Urgh!!

[BGrundee 61]

Hey everyone, just a friendly update...I had an IMR and got approved as of 12/14. DMHC overturned Aetna decision! It was a long process. If insurance is being difficult, take it up with the state. The state reviewed all my records and in matter of days after accepting my case, the decision was deemed medically necessary.