How do you appeal?

diggity · 07-25-2007, 02:10 PM

United Health Care denieds me because of "lack of objective documentation". They cover 35 BMI or more with co-morbidities, so that isn't the issue. I have 35 BMI with Hypertension, high-cholesterol, and tons of bad family history.

:help:Can anyone tell me what documentation is really needed so I can get this done ASAP?!?!?

Thanks for any help!

rkj123 · 07-26-2007, 12:35 PM

I am in the same boat you are. You should check with your doctor about having Walter Lindstrom from Obesity Law in California do your appeal. I just got word on Monday that he is taking my case. My doctor's office sent me the paperwork and within a week, he took my case. Just an idea - I guess he has great success at overturning denials.

Robin

playmate2b · 07-26-2007, 07:49 PM

I am so glad you asked that question, I go to my surgeon on the 6th but I have already been told the insurance will probably deny and I will have to appeal. It is such bull that the insurance rules what the doctors are able to do for youe health! I hope we get lots of answers from everyone that has been thru this. I have Humana PPo

peggy1011 · 07-27-2007, 09:30 AM

I have UHC and had the same problem. In the letter that they sent to me, informing me of my denial, they also included an address to write for an appeal. I had my primary doctor write a note explaining my comorbids of high blood pressure, high cholesterol, and family history of cardiac disease. I sent it in to the appeals department at UHC and was approved within 2 weeks! If the letter doesn't give you the address, call them directly and ask for it. Good luck! Let me know if I can be of any other help....
Peggy

diggity · 07-27-2007, 01:49 PM

Awesome Peggy1011!!! That is such good news. You have really made me feel so much better!

Thanks!!!

diggity · 07-30-2007, 12:33 AM

Good news! It seems my PCP knows exactly what they need for the appeal and is faxing it to UHC on Monday. I an so excited. I really think I could have my band by the end of August. My weight has been such a struggle I can't what to be given this tool. I feel like I will have a new adult life!

partpusher · 07-30-2007, 11:04 AM

Hi, I am also having the same problem with UHC, they sent me a letter saying that I did not meet the NHI standards and I have a BMI of 38.6 and co morbidities of hypertension, high cholesteral, family history of heart disease and Diabetes II. I am waiting for my liason with the hospital to help me see if I can appeal.
This is really a bummer!

Donna:help:

diggity · 07-30-2007, 11:20 AM

Get your Primary Care Physician involved. They can provide the clinical documentation you need to prove that you are severely obese with co-morbidities and medically need LAP-BAND^® surgery.

I'm not sure what NHI standards are though... explain? Some plans state that you must be 40 BMI or higher while others will state 35 BMI or higher with co-morbidities. Find out what the requirements are exactly. To get a straight answer call teh Care Coordination for United Health Care, 1-866-823-1807. Someone there can explain exactly what your companies stance on WLS.

Good Luck!

partpusher · 07-30-2007, 11:27 AM

The NIH standards are the BMI of 40 or greater or a BMI of 35 with comorbidities, which I definitely have. My PCP sent a letter with the basic overweight with health issues related and listed my medications which I take 3 dfor the diabetes, 2 for hypertension, and I for fluid retention, and a cholesteral lower med. If I don't meet the standards I don't know what does!

I really appreciate all of you fellow banders and soon to be banders, you help keep up my spirits!
Thanks,
Donna:clap2:

wendy645 · 07-31-2007, 12:44 PM

Quote:

Originally Posted by September25

Walter Lindstrom won my appeal for me. I have BCBS of Florida and they turned down my original request. The LAP-BAND^® center I was going through connected me with Walter Lindstrom and ObesityLaw.com for the free representation. Within 30 days from his office sending in all the information for the appeal, I had an approval! He is really nice and easy to deal with. I had my surgery on April 4th and have had two fills. I have lost 45 lbs so far!

Oh my gosh... wow. That's great to hear, because my insurance will put up a fight. Do you have to live in his state, or does he do nationwide?

Camurray30 · 07-31-2007, 08:31 PM

HI All - I'm living proof as well that you CAN fight UHC and win! The denied me less than 2 weeks before my surgery last Dec b/c I didn't have 5 years of morbid obesity. Even though I had other co-morbidities. It was really my fault b/c I hadn't documented them well. So from Dec until May (the 6 month period they give you) I was on a mission! I saw a sleep apnea doctor and was diagnosed with a mild case there. I also have a herniated disc and plantov faticia (achey feet) and I saw a pain management and foot doctor as well. ALL wrote letters saying they could treat me with various methods but if I lost weight the symptoms would decrease dramatically and possibly disappear. So with letter in hand, I then wrote my own 4 page letter re-stating all the facts and stats and showing them how this was really a last resort as my pain mgmt doctor had put me on limited mobility b/c of the back pain. I also had my doctor write another letter as well. The entire packet faxed was 11 pages. Guess what .. I was approved in less than 10 days!! With little help from anyone! So don't give up ... you can do it too. It just takes a little work and will power. My suggestion? Over-document them!!

partpusher · 08-01-2007, 12:12 PM

Well, I was denied because the UHC HMO that we have thru my husbands employer doesn't cover weight los surgery. So we are thinking of changing insurance plans with UHC in November and was wondering if anyone else has run into this and which UHC plan covers it best????
Any answers and help would be appreciated!
Thanks,
Donna:help::help::help:

diggity · 08-09-2007, 11:24 AM

My PCP came through and spoke directly to UHC. They were able to gather the correct documents and I have now been approved! My pre-op is August 23rd and surgery date is August 29th with Dr. Spiegel.

:whoo::whoo::whoo: