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of the Month
I don't think this is innovative, but it is something that worked
very well for me, and I don't see many use this method.
had my PCP write a letter to my insurance company requesting
insurance approval before I ever even made an appointment with a
surgeon. My PCP knew me well, had worked with me on weight
loss attempts, and had seen me succeed and then fail as I regained
have Cigna PPO, and although I knew I had asked my PCP to write a
letter in support of the surgery, imagine my surprise when I
called the insurance company to check and see if they had the info
from the surgeon only to be told "you are approved for
gastric bypass, all you need do is select a surgeon and
pre-certify for the hospitalization".
approval was on April 18th, my first surgical consult was on May
even thinking about surgery as a "remote possibility"
should, in my opinion, work with their PCP now to establish a good
history of weight loss attempts and failures.
Open RNY 6-18-01, paid 100% by insurance
|Hi my name is Nikki Dumont.
I wanted to write and let people know that you are not the only
one battling the insurance company.
I went to my pain management doctor one day and got the bad
news that he had done all he could for me and that until I could
lose 200 pounds, there was nothing he could do for my bad back. He
then mentioned gastric bypass surgery.
I went home that day and called my insurance company and they
said that gastric bypass surgery is covered if deemed “medically
necessary.” I thought, well the battle is over. How could they
deny me? I am 5'6” and weigh 397 pounds and have co-morbidities
out the ear!!
So I sent in my referral and started the wait. Well that wait
was horrible. I was denied within 24 hours of their receiving my
request. The reason was "not medically necessary!" I was
so mad. How in the world could they say that when I had a 400%
chance of a heart attack at the age of 30?
I decided there was no way I would allow them to kill me. So I
tried to think of what I could do to make them wake up. I sat down
and wrote a 5 page appeal letter expressing things I have never
expressed about myself to anyone, things I didn't even want to
admit to myself, but I did it!
Then I thought about “higher ups!!”
But I had to figure out who was higher than the almighty
insurance co. I called my State Insurance Commissioner! I told him
that I was being denied a covered benefit that I met the
requirements for. They sent me paperwork to fill out so they could
investigate. I filled out the forms, made copies and sent a
copy to the insurance co. I never sent it back to the State
Insurance Commissioner. But I would now just to make sure.
Then I also thought who else could help me. I called my State
Representative. He also was more than willing to call the
insurance company to find out what was going on.
I fought for over 25 weeks but I BEAT the insurance company. It
was the most triumphant day in my life. I was crying like a baby.
January 20th was my 6 month anniversary of being a post op! I
lost 155 pounds in 5 months and still going. I have about 80 more
pounds to go. So hang in there and fight. DO NOT let the insurance
companies win. They put some arrogant person in the approval
department who probably has never had to battle being obese, so
stand up for yourself and do whatever you have to do to get your
life back. No one else can do it for you! God Bless.
PERSISTENCE!! It took me almost a year to get approved.
|From Rebecca Tish:
I think it is very important to
"help" your insurance company out. I am sure they
receive thousands of claims for various reasons, so, to help them makes
things easier for them and helps you get a faster approval ( at
least I hope!).
I had my insurance papers turned in on Dec.
18th. They were mailed so they were probably not received by
the insurance company until the end of that week. The next
week was Christmas, so, I wasn't expecting any kind of work from
anyone. :) But much to my surprise, on Dec. 28th, I
received a phone call from my health insurance to say I was
approved. I had surgery on Jan.11, 2002 and I am doing
Now, I made sure that the insurance
company. wouldn't have to go out of their way to read my claim.
Let me tell you what I did.
First, I personally picked up my own
medical records from any doctor or weight loss center I had ever
been to lose weight. I went through those records myself and
highlighted every time a doctor called me an obese woman, any
weight related medical problems, etc.
Then I made an outline of my weight loss
and gain since high school. I am 34 years.old. now, so, I
tried to make it simple. I put the year, how much I
weighed, how much I lost, and how much I regained. I also
put what technique I had used to lose weight. I also included
my medical history on there and any co-morbidities. Along
with this I put my family medical history. I wanted the insurance
company. to see how obesity had affected me and my family.
Then I wrote a letter to the insurance
company. I used excerpts from an appeals letter that a woman
had written to get approved after denial, but, for the most part,
I wrote the majority of it. I wanted to make me a real
person to the insurance company, to show them that I do have
children, a husband, family and friends. I had the surgeon's
office send in this letter and outline with my medical records and
insurance claim. I am assuming this was a big reason I was
approved so fast. I was prepared and made myself a real
person to the insurance company.
I hope that maybe you can pass this along
to the many others who are fighting the insurance companies.
This might help in their fight. If you would like
examples of the outline and letter, I would be more than happy to
send them to you!
Jan. 11, 2002
Dr. Sidney Rohrscheib
Illinois Bariatric Center
-15 pounds and losing ...... :)
I just had a revision done of my vertical
banded gastroplasty. ,I was denied twice and was devastated. I
asked my doctor what to do and he said to fight and that is what I
did. I searched the internet and found
http://www.obesitylaw.com . The lawyer had
a gastric bypass himself so he and his wife have a practice that
specializes in fighting insurance companies over refusal to cover
weight loss surgery. It didn’t even take long. They charged
$350.00. That’s all, and we won. They are the best! They will
help you, I promise.
|Tori Kelly writes:
I waited approximately 7 weeks for my
insurance company to approve my surgery. I had a date
scheduled, but no approval. So, about 1 week before my scheduled
surgery date, I contacted our insurance agent and told him I
wanted to file a grievance against them, as they stated it would
take 2 to 3 weeks for approval. Well, I'm not sure if that
had anything to do with it, or not, but my surgeon was faxed a
pre-certification letter before my surgery, something my surgeon
said my insurance carrier had never done before.
|Lori Reese writes:
I have BC/BS (Blue Cross/Blue Shield) and just had my lap
gastric bypass on 12/7/01 (down 32 pounds so far in 5 weeks - woo,
I really didn't have any problems with approval for my surgery
with BC/BS (other than waiting about 3 weeks). The funny part is I
really had to fight with them to cover a required pre-op test (EGD)
for the surgery!
Apparently the diagnosis they kept using was associated with
weight loss MANAGEMENT which my insurance didn't cover (only
weight loss SURGERY).
I made phone call after phone call to BC/BS after receiving
each EOB (Explanation Of Benefits) denial, and each time I was
told it should be covered - we'll review it again and you'll get a
new EOB in the mail, only to be rejected again. And I wasn't about
to pay over $1300 for something my insurance should be paying!
FINALLY I wrote them a letter explaining how long this run
around had been going on and what I was being told every time, and
that this was a required pre-op
test for a surgery that BC/BS had already approved through
predetermination. I guess that finally did the trick, but they
didn't agree to pay for it until after my surgery (which had
already happened by the time all this finally got straightened
out). I guess maybe they had to see that I really had this surgery
that had been approved first?
I guess the key here is to have determination. I must have
received 6 or 7 denial EOB's from BC/BS before I finally got this
paid. If you really think something should be paid for, don't be
afraid to call your insurance company and state exactly why you
think this should be covered.
Sometimes it takes a carefully worded letter to get things
taken care of, but don't give up. A lot of times it will work. I
have fought with insurance companies before and almost always win
after I write them a letter explaining the specifics of the
situation and exactly why I think it should be covered. Gather
your facts and present them in a nice but persistent way. A lot of
times it's just a little error in how things were coded on the
billing end that automatically creates a denial.
Don't give up!
Jo Ewers writes:
At my last check-up, the nurse said that she
knew of several people who negotiated with the hospital for a
reduction of the price for surgery. If they have to pay for it
themselves, they will tell the hospital how much they are willing
to pay, and most of the time the hospital will accept it as they
want the money! Anyway, it is worth a try before giving up.
post-op Nov. 6 2001.
Lost 47 lbs so far.
Brenda in Virginia:
had my first appointment with my surgeon on March 28, 2001. My
material was submitted to my insurance company and I was denied. I
was totally crushed! I cried and thought it was useless. I
was right on the border of the insurance company’s approval
weight – 100 pounds overweight, but I had a lot of medical
problems associated with my weight.
I picked myself up and being a "research freak" I went
to work. First I called my insurance Co. and asked them what
I needed to do, name and addresses of whom I was to send the
appeal too, etc... Then I went to all the bariatric sites I could
find and looked up insurance issues, I found people with the same
insurance as I had, CIGNA, and how they dealt with it. Then
I got on the phone and called all my doctors, OBGYN, Orthopedic,
General Surgeon, family doctor, etc. I asked them to write a
letter to my insurance company and send it to me, explaining why I
need this surgery. I also stressed my need for getting them
ASAP. In the mean time, I called my drug store and got the
regular price of all the medications I was taking, and could not
take after surgery, you know the ones the insurance company was
paying for, and logged them, explaining all of this in my
won my appeal and had my surgery on August 15, 2001.
I am now 75 pounds lighter and much healthier.
Emory from Virginia