Guest guest Posted July 1, 2000 Report Share Posted July 1, 2000 In a message dated 7/1/2000 12:24:13 PM Eastern Daylight Time, CMo6331945@... writes: << It's signed by someone that says Appeal & Grievance Coordinator If anyone can advise me on this I would really appreciate it. Thanks a lot >> Sorry I forgot to sign my name Cathy in Lenoir, NC Pre-op BMI 42 A journey of a thousand miles begins with a single step Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 1, 2000 Report Share Posted July 1, 2000 In a message dated 7/1/2000 12:24:13 PM Eastern Daylight Time, CMo6331945@... writes: << It's signed by someone that says Appeal & Grievance Coordinator If anyone can advise me on this I would really appreciate it. Thanks a lot >> Sorry I forgot to sign my name Cathy in Lenoir, NC Pre-op BMI 42 A journey of a thousand miles begins with a single step Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 1, 2000 Report Share Posted July 1, 2000 In a message dated 7/1/2000 12:24:13 PM Eastern Daylight Time, CMo6331945@... writes: << It's signed by someone that says Appeal & Grievance Coordinator If anyone can advise me on this I would really appreciate it. Thanks a lot >> Sorry I forgot to sign my name Cathy in Lenoir, NC Pre-op BMI 42 A journey of a thousand miles begins with a single step Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 1, 2000 Report Share Posted July 1, 2000 In a message dated 7/1/2000 3:08:46 PM Eastern Daylight Time, beachwalkers@... writes: << My policy also excluded treatment for obesity, except in cases or morbid obesity. Their letter may have been the routine, initial rejection. Good Luck. Keep us posted. Sincerely, Bernardine , TX >> Thanks for answering my post Bernardine (you're the only one who did) I'll try what you said and write them for that information. I guess I was expecting to be turned down, but it sure knocked the wind out of my sails when the letter came. It was devastating, but I'll try what you said and keep plugging away at them and if it doesn't work I guess I'll just try to save up for it and self pay, it will just take a long, long time until I would be able to have it done. I guess anything worth having is worth waiting for, but I don't have to like it. :(:(:(:( Thank you again for taking the time to give me some advice!!!!!!!! Cathy in Lenoir, NC Pre-op BMI 42 A journey of a thousand miles begins with a single step Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 1, 2000 Report Share Posted July 1, 2000 In a message dated 7/1/2000 3:08:46 PM Eastern Daylight Time, beachwalkers@... writes: << My policy also excluded treatment for obesity, except in cases or morbid obesity. Their letter may have been the routine, initial rejection. Good Luck. Keep us posted. Sincerely, Bernardine , TX >> Thanks for answering my post Bernardine (you're the only one who did) I'll try what you said and write them for that information. I guess I was expecting to be turned down, but it sure knocked the wind out of my sails when the letter came. It was devastating, but I'll try what you said and keep plugging away at them and if it doesn't work I guess I'll just try to save up for it and self pay, it will just take a long, long time until I would be able to have it done. I guess anything worth having is worth waiting for, but I don't have to like it. :(:(:(:( Thank you again for taking the time to give me some advice!!!!!!!! Cathy in Lenoir, NC Pre-op BMI 42 A journey of a thousand miles begins with a single step Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 1, 2000 Report Share Posted July 1, 2000 In a message dated 7/1/2000 3:08:46 PM Eastern Daylight Time, beachwalkers@... writes: << My policy also excluded treatment for obesity, except in cases or morbid obesity. Their letter may have been the routine, initial rejection. Good Luck. Keep us posted. Sincerely, Bernardine , TX >> Thanks for answering my post Bernardine (you're the only one who did) I'll try what you said and write them for that information. I guess I was expecting to be turned down, but it sure knocked the wind out of my sails when the letter came. It was devastating, but I'll try what you said and keep plugging away at them and if it doesn't work I guess I'll just try to save up for it and self pay, it will just take a long, long time until I would be able to have it done. I guess anything worth having is worth waiting for, but I don't have to like it. :(:(:(:( Thank you again for taking the time to give me some advice!!!!!!!! Cathy in Lenoir, NC Pre-op BMI 42 A journey of a thousand miles begins with a single step Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 1, 2000 Report Share Posted July 1, 2000 Cathy, Just a suggestion: Write a letter to the Appeal & Grievance Coordinator and ask for a copy of the " General Exclusion from your group medical plan " that specifically excludes obesity surgery. Don't mention that you are going to appeal yet. You are just trying to understand what your benefits are under the policy. My policy also excluded treatment for obesity, except in cases or morbid obesity. Their letter may have been the routine, initial rejection. Good Luck. Keep us posted. Sincerely, Bernardine , TX > Hi Everyone, > Well, I just received a letter from United Healthcare turning down the > request for surgery and I'm not sure what to do. It has this paragraph in it > and I'm hoping some of you can tell me if it means that I just need to give > up on the insurance and start saving to self pay or what. Here is what it > says: > > United healthcare of North Carolina received a letter from Dr. > Rutledge requesting authorization of a Laparoscpic Gastric Bypass due to > morbid obesity. As documented in the General Exclusion from your group > medical plan, obesity treatment is specifically excluded from coverage. > Therefore, United healthcare of NC is unable to authorize the services. > > Please note, as approved by the NC Department of Insurance, that the > grievance process does not apply to grievances based solely on the fact that > United healthcare of NC does not provide benefits for the health care service > in question. Unitedhealthcare of NC is unable to consider an appeal request > for these services. > > It's signed by someone that says Appeal & Grievance Coordinator > > If anyone can advise me on this I would really appreciate it. Thanks a lot. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 1, 2000 Report Share Posted July 1, 2000 Cathy, All the best to you! Keep fighting! Bern > In a message dated 7/1/2000 3:08:46 PM Eastern Daylight Time, > beachwalkers@h... writes: > > << My policy also excluded treatment for obesity, except in cases or > morbid obesity. Their letter may have been the routine, initial > rejection. > > Good Luck. Keep us posted. > Sincerely, > Bernardine > , TX >> > > Thanks for answering my post Bernardine (you're the only one who did) I'll > try what you said and write them for that information. I guess I was > expecting to be turned down, but it sure knocked the wind out of my sails > when the letter came. It was devastating, but I'll try what you said and keep > plugging away at them and if it doesn't work I guess I'll just try to save up > for it and self pay, it will just take a long, long time until I would be > able to have it done. I guess anything worth having is worth waiting for, but > I don't have to like it. :(:(:(:( Thank you again for taking the time > to give me some advice!!!!!!!! > > Cathy in Lenoir, NC > Pre-op > BMI 42 > A journey of a thousand miles begins with a single step Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 1, 2000 Report Share Posted July 1, 2000 Cathy, All the best to you! Keep fighting! Bern > In a message dated 7/1/2000 3:08:46 PM Eastern Daylight Time, > beachwalkers@h... writes: > > << My policy also excluded treatment for obesity, except in cases or > morbid obesity. Their letter may have been the routine, initial > rejection. > > Good Luck. Keep us posted. > Sincerely, > Bernardine > , TX >> > > Thanks for answering my post Bernardine (you're the only one who did) I'll > try what you said and write them for that information. I guess I was > expecting to be turned down, but it sure knocked the wind out of my sails > when the letter came. It was devastating, but I'll try what you said and keep > plugging away at them and if it doesn't work I guess I'll just try to save up > for it and self pay, it will just take a long, long time until I would be > able to have it done. I guess anything worth having is worth waiting for, but > I don't have to like it. :(:(:(:( Thank you again for taking the time > to give me some advice!!!!!!!! > > Cathy in Lenoir, NC > Pre-op > BMI 42 > A journey of a thousand miles begins with a single step Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 1, 2000 Report Share Posted July 1, 2000 Cathy, All the best to you! Keep fighting! Bern > In a message dated 7/1/2000 3:08:46 PM Eastern Daylight Time, > beachwalkers@h... writes: > > << My policy also excluded treatment for obesity, except in cases or > morbid obesity. Their letter may have been the routine, initial > rejection. > > Good Luck. Keep us posted. > Sincerely, > Bernardine > , TX >> > > Thanks for answering my post Bernardine (you're the only one who did) I'll > try what you said and write them for that information. I guess I was > expecting to be turned down, but it sure knocked the wind out of my sails > when the letter came. It was devastating, but I'll try what you said and keep > plugging away at them and if it doesn't work I guess I'll just try to save up > for it and self pay, it will just take a long, long time until I would be > able to have it done. I guess anything worth having is worth waiting for, but > I don't have to like it. :(:(:(:( Thank you again for taking the time > to give me some advice!!!!!!!! > > Cathy in Lenoir, NC > Pre-op > BMI 42 > A journey of a thousand miles begins with a single step Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 2, 2000 Report Share Posted July 2, 2000 To the person who has United Healthcare in NC, I also have it and did not have a problem. Is it through your company or your husbands? in Durham and moving to Chapel Hill Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 2, 2000 Report Share Posted July 2, 2000 To the person who has United Healthcare in NC, I also have it and did not have a problem. Is it through your company or your husbands? in Durham and moving to Chapel Hill Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 2, 2000 Report Share Posted July 2, 2000 To the person who has United Healthcare in NC, I also have it and did not have a problem. Is it through your company or your husbands? in Durham and moving to Chapel Hill Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 2, 2000 Report Share Posted July 2, 2000 Cathy, Do you have PPO or EPO? Do you have to have a referral? What is your co-pay for a regular visit and for perscriptions? I need to know these answers before I can help your with your attack. in Durham and moving to Chapel Hill Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 2, 2000 Report Share Posted July 2, 2000 Cathy, Do you have PPO or EPO? Do you have to have a referral? What is your co-pay for a regular visit and for perscriptions? I need to know these answers before I can help your with your attack. in Durham and moving to Chapel Hill Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 2, 2000 Report Share Posted July 2, 2000 Cathy, Do you have PPO or EPO? Do you have to have a referral? What is your co-pay for a regular visit and for perscriptions? I need to know these answers before I can help your with your attack. in Durham and moving to Chapel Hill Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 2, 2000 Report Share Posted July 2, 2000 > To the person who has United Healthcare in NC, > > I also have it and did not have a problem. Is it through your company or > your husbands? > > in Durham and moving to Chapel Hill It is through my husbands workplace. Cathy in Lenoir, NC Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 2, 2000 Report Share Posted July 2, 2000 > To the person who has United Healthcare in NC, > > I also have it and did not have a problem. Is it through your company or > your husbands? > > in Durham and moving to Chapel Hill It is through my husbands workplace. Cathy in Lenoir, NC Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 2, 2000 Report Share Posted July 2, 2000 > To the person who has United Healthcare in NC, > > I also have it and did not have a problem. Is it through your company or > your husbands? > > in Durham and moving to Chapel Hill It is through my husbands workplace. Cathy in Lenoir, NC Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 3, 2000 Report Share Posted July 3, 2000 > Cathy, > > Do you have PPO or EPO? Do you have to have a referral? What is your co-pay > for a regular visit and for perscriptions? I need to know these answers > before I can help your with your attack. > > in Durham and moving to Chapel Hill Hi , I have a POS, do not have to have a referral, regular visit 15.00 co-pay, prescriptions 10.00 co-pay. It does say in my ins. policy that any weight loss program, weight loss drugs or weight loss surgery is excluded, but it also says unless medically nessasary. The letter that they sent me Saturday says that obesity treatment is specifically excluded from coverage and that they are unable to consider an appeal request for these services, so I'm just not sure what to do. Thanks for your help. Cathy in Lenoir Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 3, 2000 Report Share Posted July 3, 2000 > Cathy, > > Do you have PPO or EPO? Do you have to have a referral? What is your co-pay > for a regular visit and for perscriptions? I need to know these answers > before I can help your with your attack. > > in Durham and moving to Chapel Hill Hi , I have a POS, do not have to have a referral, regular visit 15.00 co-pay, prescriptions 10.00 co-pay. It does say in my ins. policy that any weight loss program, weight loss drugs or weight loss surgery is excluded, but it also says unless medically nessasary. The letter that they sent me Saturday says that obesity treatment is specifically excluded from coverage and that they are unable to consider an appeal request for these services, so I'm just not sure what to do. Thanks for your help. Cathy in Lenoir Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 3, 2000 Report Share Posted July 3, 2000 > Cathy, > > Do you have PPO or EPO? Do you have to have a referral? What is your co-pay > for a regular visit and for perscriptions? I need to know these answers > before I can help your with your attack. > > in Durham and moving to Chapel Hill Hi , I have a POS, do not have to have a referral, regular visit 15.00 co-pay, prescriptions 10.00 co-pay. It does say in my ins. policy that any weight loss program, weight loss drugs or weight loss surgery is excluded, but it also says unless medically nessasary. The letter that they sent me Saturday says that obesity treatment is specifically excluded from coverage and that they are unable to consider an appeal request for these services, so I'm just not sure what to do. Thanks for your help. Cathy in Lenoir Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 3, 2000 Report Share Posted July 3, 2000 Hi Cathy-- My policy also exludes obesity surgery unless medically necessary. I suspect that nearly everyone's policy says this. This is the insurance company saying, " Well, if you're 30 pounds overweight, we'd suggest you try another alternative, at your own expense. " The insurance company sent you that letter for one of two reasons: (1) they're hoping that you'll believe that the surgery really is excluded, and go away, or (2) your existing policy may predate the policy they're actually reviewing, so that they assume that the surgery is excluded because of the " type " of policy that you have, but don't realize that you have an earlier version that will allow for the surgery when " medically necessary. " >I'm just not sure what to do.> You get in there and fight, girl! The generally accepted standards for " medically necessary " are the factors that Dr. R requires before he'll even accept a patient: BMI> 35 with co-morbidities, or a BMI> 40, even without co-morbidities. Bottom line: If you meet these standards, then the surgery is " medically necessary. " Get all the medical backup for these standards (i.e. these are the standards adopted by the National Institutes of Health, etc.) and include this material in your appeal. It might help if you get your PCP to specifically state in his/her referral letter (or the additional letter that you're going to request to bolster your appeal!) that he/she is recommending the surgery for you because it is " medically necessary. " My PCP's recommendation letter specifically stated this. (My ins. company declined me anyway, but I've written an initial appeal letter, and I gather from the extremely helpful " medical review " rep that is helping me that I will likely get approved this Thursday. Keep your fingers crossed for me!) Your insurance company's claim that they are " unable to consider an appeal " sounds wrong to me. First take a look at what your policy says about your right to an appeal--it's the policy that controls, and not what the company is now saying. Second, an appeal process is mandated by state law in most states. If you like, let me know what state you live in, and I will look up the law in your state and send it to you. (I'm an attorney, but I don't currently practice, so please don't hold hate me! LOL) By all means, don't just let it go. Many (if not most) insurance companies decline this type of surgery at the first request, and many people assume this to be the answer, and just go away. That's exactly what the insurance company is banking on. It's a " wear them down " kind of mentality--don't let them wear you down! Enough time for me on the soapbox--whatever you do, I wish you the best of luck, and let me know if I can help. --a Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 4, 2000 Report Share Posted July 4, 2000 Cathy, I went out of town yesterday so I couldn't reply. However, using the " medically necessary " terminology, get your PCP to write a very strong letter suggesting how much this surgery is necessary and dig deep into your family background. Talk about the weight problem throughout the generations and how you must break the cycle of hbp, strokes, heart attacks, etc. If that doesn't work, see if you can upgrade your policy because of this " emergency. " We have PPO with a 5.00 co-pay for everything. Hope this helps. in Durham, moving to Chapel Hill soon. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 4, 2000 Report Share Posted July 4, 2000 Cathy, I was in Lenoir County yesterday in Kinston. If I had of had your telephone number we could have talked about this on the phone or in person. Sorry, I didn't make the connection earlier. in Durham, moving to Chapel Hill soon. Quote Link to comment Share on other sites More sharing options...
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