insurance appeal question

03-26-2004, 11:53 AM

HI, I am new on this board, I normally write on the obesity help board, I have been denied by my insurance bc/bs il and am trying to appeal, I want to ask my HR dept to write a letter since my insurance is thru my work, I just need ideas for what to write, I heard that alexandra on this board fought her insurance and won, any suggestions would be great. Thanks Nicki

**Alexandra** · 03-26-2004, 02:14 PM

Hi Nicki,

Tee hee! What am I, famous?

The first thing to do in planning your appeal is focus on exactly why your petition for authorization was denied. Was it because you don't qualify for WLS? Did they approve you for WLS but just not for the band? What is their reasoning? That's the first all-important step and we can figure out where to go after that.

So what did your denial letter say?

03-26-2004, 02:25 PM

Hi, the letter says this
no benefits are available for Gastric Banding (including the adjustable lap band)Gastric Banding (including the adjustable lap band) permormed lap or open and consisting of and external band placed around the stomach, is considered experimental or investigational as treatment of morbid obesity.

what do you think??

thanks Nicki

CathyFalb · 03-26-2004, 02:54 PM

Call Inamed and get some info from them showing that the Lap Band is not experimental. Unfortanatly the band is still kind of new and some insurances say that it is experimantal. Don at Inamed is great and will help you in any way that he can. Alot of insurances deny you and hope that you don't appeal. You may also want to consider Walter Lindstrom. He is a lawyer in California that has helped alot of people get their denial turned around. You can find him at www.obesitylaw.com. Don't give up though. If you have made a decision to be banded then don't go down without a fight. Good luck!

**Alexandra** · 03-26-2004, 05:07 PM

Nicki, Cathy is right that a good place to start with this appeal is with Don Mills at Inamed. You can reach him at don.mills@inamed.com.

The other thing you should do now is find your plan documents--your insurance plan paperwork, the certificate, the booklet, whatever you want to call it--and find the carrier's appeal procedures. The letter you received probably gives you a thumbnail of how to appeal, but you should also find out the big picture. How many times will they entertain internal appeals? Is there any provision for third-party intervention?

If there's any way you can find out, see if you can discover how long after FDA approval other types of procedures have been taken off the "investigational" list. That's the sort of thing that is slow to come, and carriers are under no pressure to move it along. Just because the FDA says it's an accepted procedure, your carrier is not obligated to agree. And their opinion that it's still investigational is going to be a company-wide opinion, so it's very unlikely that any internal review is going to change that.

So contact your state's department of insurance. (I'm sure they'll have a website where you can find this information.) See if they offer a review process for HMO decisions. Start researching what that is and how you'd have to proceed there. Here in NJ I had to exhaust my carrier's internal appeals before taking my case to an external review, but your state may be different.

The good news is that they did not deny your request saying you do not qualify for WLS. So whether it's via appeal of through the passage of time, eventually they will be paying for your weight-loss surgery, assuming it's still medically necessary.

You have to decide whether you're willing to fight and/or wait for the band, or go with their current favorite method, bypass. I was willing to fight AND wait, if necessary. There was no way I'd consider the bypass so all of my correspondence included the fact that for me it was either this surgery or no surgery. I gave reasons. And since everyone agreed that WLS was medically necessary for me--which no one had ever disputed--I was going without medically necessary treatment based on their arbitrary decision. That's not the kind of thing an external review board likes to see.