Denied - Not Medically Necessary

sarcar · 05-19-2005, 07:10 PM

I received verbal notification that I needed to follow through with a 3-month diet monitored by my primary physician. Now I get a letter stating that it is being denied because "Our review has determined the services to no be medically necessary." I am 130 pounds overweight. High blood pressure, two knee surgeries (and about to have a knee replacement if I can't get weight relief). Diabetes & heart problems run in my family. What more do they want?

Do I go on the diet hoping that what they verbally tell me is true since I complied with 100% of the first requirements? Or do I appeal now and still start the diet? This is a HUGE let down as I was so prepared to do this surgery this summer and get on with my life.

Carolyn

bandit · 05-19-2005, 08:37 PM

Can u appeal now AND go on their diet while ur waiting? Dont u get a few appeals? Then even if they deny ur appeal, at least uve started ur diet and u can appeal again after u compleat it. I know quite a few people here have a hard time with insurance and sometimes the appeals work and sometimes they dont. I never know what way to bet on it when u guys post about this. Like sometimes the appeals get approved like in days and sometimes very deserving people get denied over and over. Shhhheshhhh. Health care is so unpredictable. I knew I would be self pay form the get go so at least I didnt have to fight with some dumb insurance co. Like any of us need that stress too!

**Alexandra** · 05-20-2005, 06:27 AM

Carolyn, that is so frustrating! Sounds like a classic example of the left hand not knowing what the right hand is doing.

The "not medically necessary" line is probably their catch-all denial phrase. Do your diet and when it's over appeal again. Make sure that in the appeal the question of medical necessity is addressed by your doctor in addition to providing the notes/evidence of the diet that your carrier wants.

It's just an obstacle, not a defeat. You'll get there!!

I'llsucceed · 05-20-2005, 08:44 AM

I also agree you need to start a medically overviewed diet today & go see the doc every three weeks or so & document it & than also start gearing up for the appeal right noe. 3 months is going to go very fast they told me an entire year when I was denied. You can still win this -fight fight fight!

New Hope · 05-20-2005, 10:22 AM

Carolyn, don't give up! I think it's pretty standard for insurance cos. to first turn you down. A lot of people stop at that point and don't pursue it any further. As frustrating as it is, please jump through all their hoops. I was denied, appealed, and eight months later got my band. You're worth it, so please do what needs to be done and best of luck to you!

sarcar · 05-20-2005, 10:52 AM

Thanks all - this makes me feel better. Does anybody know what I am suppose to accomplish on this diet. I can succeed for 3 months in losing weight but not continue to be successful and gain it all back plus later. Do they want to see weight loss, no weight loss, partial loss?????

I know I over analyze but I just want to make sure I give them what they want to see.