My grievance letter..... - ThinnerTimes

QueenB · 10-13-2004, 01:29 PM

........or is it an appeal letter ? Anyhow this is draft #1 what do you think...should I add or delet anything?

To Whom it May Concern,

I have received, from Sharp Community Medical Group, a notice of denial of medical coverage in response to Dr. Schoengold’s request for a referral on my behalf to consult a bariatric surgeon. The letter, dated October 11, 2004, stated that I do not meet Sharp Health Plan’s medical necessity criteria, specifically that there is no evidence of a medically supervised weight loss program for a six month period in the 3 years prior to the request for service being submitted. However, I believe, the facts I have stated below will show how my case does show medical necessity and was considered incorrectly.

I am a 27 year-old female, wife and mother of 4 young children. I am obese. At 5ft 4 inches and an average of 215lbs I suffer daily with co-morbidities caused by my weight. I suffer from sever back pain caused by degenerative disc disease and herniated discs complicated if not caused by my being overweight. I have high cholesterol and grossly high triglycerides. I deal with stress incontinence, knee, hip and joint pain and discrimination on a daily basis. These issues alone should constitute medical necessity.

Without a personal sob story I would like you to take into consideration the nearly 20 years I have been dieting unsuccessfully. You can read for yourself in my diet history (attachment 1), that does consist of medically supervised and also unsupervised weight loss attempts from the time I was 9 years old, that I have completed programs lasting for 6 months and longer. I managed to loose substantial amounts of weight only to regain what I lost and, generally, a hefty amount more when I had finished the program or diet. I am submitting doctor’s records to show that I have been attempting weight loss for many years and some of those attempts were supervised. I hope that these records will show my commitment to my ultimate goal of no longer struggling with my health and weight.

I would also like to bring to the attention of Sharp Community Medical Group their recommendation of breastfeeding. It is stated on Sharp.com that you have a commitment to helping me give my child the best possible start in life. In the last 3 years, starting in August 2001 up until the present I have been either pregnant, breastfeeding or both. In the last 36 months I have been breastfeeding for 24. I have maintained a healthy diet in order to give my children the best possible nutrients in my breast milk. I also managed to loose all of the weight I had gained during pregnancy by nursing and being active. Keeping my breast milk nutritious enough for my child requires that I do not take any drastic measures to reduce my body weight. I did get both Dr and pediatrician advice and opinion when I decided to start the Suzanne Somers diet and Weight Watchers. I was given the go ahead as long as my daughter(s) continued on the same growth curve and I wasn’t showing any signs of undernourishment. I would assume this would be taken into account when reviewing the actions I have taken over the last 3 years in my weight management journey. Perhaps going back in my history a bit farther would be pertinent in this situation.

My biggest concern, however, with your request that I start yet another diet, is the effect my dieting has had on my children. I have 4 children ranging in age from 10 months to 9 years. I can see in my 9 year old what effects my dieting has on HIM; yes he is a young man. A healthy, strong and fit young man who consciously started cutting out carbohydrates because he has seen me doing so. He has adopted such things as not eating after 6:30pm, questioning portion size at restaurants and weighing foods after watching me incorporate so many of these habits and more into my daily ritual in weight loss. A happy, intelligent and caring young man who wants to join the gym with me on top of his thrice weekly karate classes and Saturday sparing because he has seen me add weight training to my cardio. I would like nothing more than for my youngest children, 2 girls age 2 and 10 months, to have no memory of me dieting or being overweight in pain. I would like the lasting psychological impact on my children seeing me start another diet program to meet Sharp Community Medial Group requirements taken in to serious regard.

I am afraid that, as a mother who wants to do the best thing for her family and set a good example for her children, I can’t see how another diet will be anything other than a loss of precious time that I could be spending taking steps that will improve my overall health including lowering my cholesterol and triglycerides, alleviating excruciating back pain and helping with the emotional aspects of being overweight, permanently. In reviewing the attachments, Dr’s records and letters, I hope you will find that I have shown great cause for reconsideration of Sharp Community Medical Groups denial for medical services based on proof of medical necessity.

Thank you for your time,

Americanwoman397 · 10-13-2004, 01:48 PM

Well with that letter you are approved oh wait I'm not the insurance company. Darn well I would approve you. That letter states what they need to hear I think but I never had this problem. I'm sure you'll get lots of feedback from people who have gone through this. Good luck on your journey. Hope every thing works out

Christina · 10-13-2004, 02:05 PM

That was a great letter. However, Insurance companies are really interested in $$ amounts. There are great appeal letters out there.. and I have a letter I can send you. Basically I would add that the cost-effeciveness of the surgery out weighs the added expense of maintaining an unhealthy morbidly obese individual. Because when it comes down to it, having surgery helps to alleviate medical expenses because most if not all signifigant co-morbidities are resloved after signifigant weight loss.

Sometimes putting documentation such as that helps. I will see what I can find to add to your letter. Not trying to criticize it, it's a great letter.. but all they care about is number crunching..

QueenB · 10-13-2004, 02:56 PM

I just got off the phone with my PCP office who had suppervised my Phen-Fen back in 96-97. They said my records would be in today last time I called and when I called today they said they weren't in the batch they recieved and another batch would be in early next week but they may not have them at all

They made it sound like they for sure would be in when I talked to them last time and now I am so sad

I do have a Dr. appt tomorrow at 2:15 to see my current PCP and see what she has to say.......

Thanks for all your input and advice, I appreciate it.

watergirl · 10-14-2004, 07:14 AM

Christina said it really well. The insurance company is looking out for it's bottom line. Addressing the lower medical costs post WLS is a great suggestion.

Fight the good fight!

bridgetgirl · 10-14-2004, 10:26 AM

I was thinking about this last night... you being denied and all and I think it's BS! Now we have insurance companies putting a staute of limitations on weight loss attempts... that's crap! I say you go to an obesity lawyer... get a consult with them and see if they are able to assist you.. in another 6 months after you have FAILED once again... (not trying to be negative here) there will be another excuse, like a change in coverage or something..... this is just my 2 cents.

I get so sick of all this prejudice and circumstance with people who are or were ever MO! It's like we carry this scarlet letter, and we are constantly being reminded of how we cant achieve, or be treated like "everybody else" This is our nations most widely accepted prejudice and I am getting so tired of it. By them telling you that they need a WLS program within 3 years is still bullying..... where is it written that is their protocol...? Like I said I think its BS and bullying... get an attorney girl or consult with one at least that specializes in obesity help! I know its just my opinion but does any of this make sense to y'all?

watergirl · 10-14-2004, 10:34 AM

Here is my question to this whole 6 month supervised diet protocol. If you lose weight during this process, will you still be within the 40+ BMI or 38+ with co-morbidities to qualify for surgery. Would any doctor touch you? I know Dr. C/Kelly won't.

I mean that's great if you can lose the weight, but we all know that more weight will come back on after the program is over.

Bridget, I think getting a consult from a MO lawyer is a good idea.

Jay · 10-15-2004, 08:08 AM

What I think made the turn for Sharps' for me in my rebuttal letter (yes I got the same one you did) was the fact that my insurance company refused to pay for the Sharps supervised weight program because of the low success rate. They wanted 900 a month. At the projected weight loss rate it would have cost more than the surgery. What Briggett and others said. It is a money issue. When my insurance company said no ( I asked them for a comperable life insurance policy to someone my age that weighed 155 LBS.
I think these things helped me, but I am not sure. I also think on the rebuttal letter you should go into the "sob story"
My feeling is the Sharps will shoot everyone down once, just to see how committed you are.
Good luck
Oh BTW 3 weeks post OP -33 LBS!

Bigdave · 10-15-2004, 08:13 AM

I have SCMG and have had absolutley no problems. Have you done Weight-Watchers, Jenny Craig, or any other "supervised" weight loss program?

QueenB · 10-15-2004, 10:21 AM

I have done WW twice, and Jenny Craig for 9 months they want recent....within the last 3 years and all of those are prior to that.

I was on the phone for next to ever on Wednesday talking to both Sharp Health Plan and SCMG. I have to say the woman I talked to at SCMG was amazing, she gave me every Dr's appt including the date and with what Dr (OB, PCP, urgent care etc.....) for the last 3 years. She suggested that I go to my PCP and go over each visit (I have been monthly since February 2004) to see if there was anything in their notes about WL. Funny that I had started WW in Feb 2004 per my Dr but I thought it wouldn't count, the rep said if your Dr. wil back you up it most certianly WILL count. She encouraged me to keep fighting and said she knew there were alot of hoops but eventually everything would come to reality. It was so nice talking to someone like that, even if she was just a customer rep answering phones.

SO I went to the Dr's yesterday afternoon. When I told her I had gpotten a denial she said "of course silly, you are not fat enough" I almost died! This is the Dr who said she do everything she could to get this approved for me. She continued with.....they won't even concider you with a BMI of 36......36!!!! I said I am pretty sure I am at 37 and she says they won't even concider until 38. I refuse to purposefully gain any weight.....so I took a deep breath and regrouped and remembered I hadn't been denied because I wasn't "fat enough" but rather for the 6 month diet. So I told her that and showed her the denial letter. She went back over all my visits and starting in February it is clear I was attempting weight loss. I started at 218.9 and through May dropped to 198, then the back pain flaired up (June) and I had to cut out exercise and you can see the weight creeping back up although I was still following the WW points. When I discontinued WW in early Sept the weight just packed on. She was amazed she hadn't seen that earlier. She said that should qualify me for a 6 motnh attempt in the last 3 years AND IT'S ALL DOCUMENTED!!!!!!! I had also totally forgotten about the letter (albeit CHEEZY!) my ortho had written. I remembered and brought it up and she said it could definitely help.........I had it in my truck so I left her a copy. I don' want to get my hopes up but this is just a resubmittal of the referral request with new info so I still have appeals and grievances left if that doesn't convince them.

INPUT PLEASE?

PS I was disgusted to find I have actually GAINED weight inthe last 3-4 weeks 5 lbs! I am so angry but I think I may be PMS'ing.....yeah, that's it LOL