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...
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...
Guest guest Posted July 4, 2000 Report Share Posted July 4, 2000 Hi a, thanks for your reply, I would like the information that you so kindly offered. I live in Lenoir, North Carolina. The papers that I have from United Healthcare says: Some Exclusions: Services which are not medically neccessary or medically appropriate. Then when you go down the list it says: All expenses related to physical reconditioning programs, acupuncture, weight loss programs, treatments, surgeries or modification therapies. I guess what really upsets me is if I had a drug problem or I was an alcoholic they will pay for treatment for that, but the fat that is slowly killing me they refuse. I guess I'm just lost on how to fight them. I'm sorry for venting, anyway if you are still willing to send me that info my email address is: CMo6331945@... Thanks alot!!! > 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 Hi a, thanks for your reply, I would like the information that you so kindly offered. I live in Lenoir, North Carolina. The papers that I have from United Healthcare says: Some Exclusions: Services which are not medically neccessary or medically appropriate. Then when you go down the list it says: All expenses related to physical reconditioning programs, acupuncture, weight loss programs, treatments, surgeries or modification therapies. I guess what really upsets me is if I had a drug problem or I was an alcoholic they will pay for treatment for that, but the fat that is slowly killing me they refuse. I guess I'm just lost on how to fight them. I'm sorry for venting, anyway if you are still willing to send me that info my email address is: CMo6331945@... Thanks alot!!! > 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 Hi a, thanks for your reply, I would like the information that you so kindly offered. I live in Lenoir, North Carolina. The papers that I have from United Healthcare says: Some Exclusions: Services which are not medically neccessary or medically appropriate. Then when you go down the list it says: All expenses related to physical reconditioning programs, acupuncture, weight loss programs, treatments, surgeries or modification therapies. I guess what really upsets me is if I had a drug problem or I was an alcoholic they will pay for treatment for that, but the fat that is slowly killing me they refuse. I guess I'm just lost on how to fight them. I'm sorry for venting, anyway if you are still willing to send me that info my email address is: CMo6331945@... Thanks alot!!! > 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 February 20, 2003 Report Share Posted February 20, 2003 I am having problems with my insurance. I could shoot my husband. He changed our insurance as of the first of this year. We had Aetna POS or PPO (can't remember which one) and now we have an HMO!!!!!!! So of coarse they don't want to pay. I could have already had my surgery with Dr. M and B. But now I don't know what to do. I am fighting with my husbands company to switch us back to the PPO or POS. Has anyone ever done anything like this? I am witting letters and calling but they said no way they have had too many problems with the HMO so they can't switch anymore people. By the time the HMO approves the surgery I may not be able to do it!!!! If anyone has any ideas please, I need the help. Thank You Mitzie Quote Link to comment Share on other sites More sharing options...
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