Denial Letter - ThinnerTimes

TONYAGASTON · 06-11-2004, 05:44 AM

Hello everyone. Got my letter from Pacificare. I was denied. They denied it because because there was no documentation of "failed less invasive methods of weight loss" and the fact that it was not noted how I was at a high risk of developing obesity-associated morbidity or mortality". Less invasive would be....low calorie dieting, increased physical activity, behavioral therapy and pharmacotherapy. I am going to appeal, but not quite sure of how my letter should read. I have been on every diet under the sun. I have been put on topamax to help. I have been to a nutrionist(sp?) I have increased my exercise to help in my weight loss. I even push myself to do my exercise some days, because of constant pain I am on vicodan extra strength to help me. Any pointers would be appreciated. I will be thinking about how to word my letter this weekend, and will write it sunday nite and sending it out Monday. Another question.....should I still go to the educational seminar that was scheduled for me on Tuesday?

thanks
Tonya

lealphachienne · 06-11-2004, 07:05 AM

Definitely go to the seminar. I went to my seminar in January and didn't get my approval until April. The seminar is good for a year, so you have time to get everything in order. Also, enlist help of your MD who can write a letter too. I was denied the first time for the same reason. I didn't bother with an appeal process. I waited a few months and had my MD submit another referral request with additional information and a letter from her along with a copy of my psychologist's letter. Since January 1, 2004 many insurances are getting tougher on their approval process. Many insurances that use to cover WLS are beginning to phase it out. There are others here who can help with an appeal letter. It doesn't hurt to try many approaches at once to bang the insurance on the head and tell them to wake up.

Good luck and hang tough

Marie
lap 5/28/04
235/219/120

Suzanne-photog4fun · 06-11-2004, 08:09 AM

Hang in there, Tony! Many people get denied the "first round". They want you to jump through more hoops and hope that you'll give up....DON'T. It's worth the fight! And definitely go to the seminar! My niece is currently going through the same challenge for the same reason. Suzanne

Blueyz · 06-11-2004, 08:24 AM

I was denied the first round, too. I had proof of doctor supervised weight loss programs, but it was not submitted by my doctor the first time. I appealed the referral and within a week, it was overturned. My doctor rewrote the referral and included all of my documentation the second time around. It was great. My doctor told me he would be my advocate and everyhthing would work out. Stay tough! I hope everythig works out for you. FYI, I have Blue Shield HMO and thought I would've had a rougher time.