First Denial Received
It's been a while since I've posted. I had my information session at the University of Chicago on my birthday, April 26th, and my surgeon/psych/nut consult on April 27th. Everything went extremely well, and I was approved by Dr. Alverdy's team for surgery on April 29th with very few requirements (only needed a letter of medical clearance from my PCP, a copy of my latest hemoglobin A1c bloodwork, and participation in a mandatory PREP course). When Tracie from Dr. Alverdy's office called me yesterday to go over what paperwork was still needed, I found out she had already submitted the prior approval request on May 3rd. Needless to say, I was ecstatic, and also worried.
I received my denial letter in the mail yesterday, citing the following: "Based on the information available to us, this request does not meet medical necessity and is being denied as of May 3, 2011 based on the following: There is no documentation of physician monitored weight loss attempts within the two years prior to the procedure as required by medical policy."
I know there are many, many posts out there about being denied and asking how to proceed. I apologize in advance, because I am very frazzled right now. I'm not sure what my next step is. I don't know if I need to contact Dr. Alverdy's office, or if they will contact me, or if they will contact the insurance, or if I need to contact my PCP. I know I just received this Friday, but apparently there is a time limit for appeal. Any help and advice would be so appreciated right now.
The hard part for me, I guess, is that I don't really understand how they access your personal medical records from your PCP in the first place. There is a section on the denial letter that says: "Your physician has the right to speak with the Wellmark Medical Director regarding the requested service by calling the customer service number on the member's health card."
Sorry this is so long, but right now I don't know my next step, and I don't like to feel helpless. If anyone can help me with what I should/can be doing, I would be so happy and relieved. Thanks for listening.
I received my denial letter in the mail yesterday, citing the following: "Based on the information available to us, this request does not meet medical necessity and is being denied as of May 3, 2011 based on the following: There is no documentation of physician monitored weight loss attempts within the two years prior to the procedure as required by medical policy."
I know there are many, many posts out there about being denied and asking how to proceed. I apologize in advance, because I am very frazzled right now. I'm not sure what my next step is. I don't know if I need to contact Dr. Alverdy's office, or if they will contact me, or if they will contact the insurance, or if I need to contact my PCP. I know I just received this Friday, but apparently there is a time limit for appeal. Any help and advice would be so appreciated right now.
The hard part for me, I guess, is that I don't really understand how they access your personal medical records from your PCP in the first place. There is a section on the denial letter that says: "Your physician has the right to speak with the Wellmark Medical Director regarding the requested service by calling the customer service number on the member's health card."
Sorry this is so long, but right now I don't know my next step, and I don't like to feel helpless. If anyone can help me with what I should/can be doing, I would be so happy and relieved. Thanks for listening.
~Tara
HW: 318 / SW: 280 / GW: 150 / CW: 263
HW: 318 / SW: 280 / GW: 150 / CW: 263
it is ok this surgery is important for your health and well-being to get the denial is difficult. if the only reason they said was because of the monitored weight loss attempts within the last 2 years and nothing else, that is probably simplier than you may think, you will have to do a lot of this stuff yourself, as it is your contract with the insurance co, not you drs. ok so...
1. if you don't have a copy of your adhesion contract (subscriber agreement) get it and READ it (insurance co hope subscribers will not ask for or read this, and this is NOT the benefits summary) all and understand it, especially the time frame for appeals, this is very imp. because if you go beyond this, then you have no prayer in the world.
2. call the insurance co. and ask for a copy of the "medical policy" govering the requested surgery, since you have denied, they must provide this to you.
3. did you go to your pcp in the last 2 years, how about gyn? how about another medical professional? If you went, I am sure you talked about weight loss, eating less, exercising more, etc, you can use that. I mean come on this is a bunch of BS anyway and it is a way for insurance co to deny you. what is the dr suppossed to be with you while you eat every meal? what the heck does the insurance co mean by that anyway-that was a rhetorical question btw-whenever I see that denial it is just so stupid
4. The surgeon who submitted your pre authorization is the one who submitted medical info., that does not mean s/he is the one who "monitored" your weight loss attempts.
5. Find out what organizations govern medical necessity denials in your state? Insurance commissioners, Dept of health etc and get info. from that organization on the procedure that insurance co MUST follow when they deny a medical procudure.
hang on you are in for a bumpy ride, but it will set you up to be proactive for the DS.....
You will have to become very educated in the BS of denials
1. if you don't have a copy of your adhesion contract (subscriber agreement) get it and READ it (insurance co hope subscribers will not ask for or read this, and this is NOT the benefits summary) all and understand it, especially the time frame for appeals, this is very imp. because if you go beyond this, then you have no prayer in the world.
2. call the insurance co. and ask for a copy of the "medical policy" govering the requested surgery, since you have denied, they must provide this to you.
3. did you go to your pcp in the last 2 years, how about gyn? how about another medical professional? If you went, I am sure you talked about weight loss, eating less, exercising more, etc, you can use that. I mean come on this is a bunch of BS anyway and it is a way for insurance co to deny you. what is the dr suppossed to be with you while you eat every meal? what the heck does the insurance co mean by that anyway-that was a rhetorical question btw-whenever I see that denial it is just so stupid
4. The surgeon who submitted your pre authorization is the one who submitted medical info., that does not mean s/he is the one who "monitored" your weight loss attempts.
5. Find out what organizations govern medical necessity denials in your state? Insurance commissioners, Dept of health etc and get info. from that organization on the procedure that insurance co MUST follow when they deny a medical procudure.
hang on you are in for a bumpy ride, but it will set you up to be proactive for the DS.....
You will have to become very educated in the BS of denials
Like Airbender said... after reading here about some or many of the insurances needing 3 months to 6 months to a year of weight and diet checks thought it would be a good idea.
Many insurances have a different requirement for revision in their policies too.
I had to go to all my physicians offices and get copies of all my visits showing my weight, and when I saw them, along with the letter stating I was counseled each time of weight issues.
I even did where I had, on purpose, the last 6 visits-made them state in there was counseled on diet...
But any appointment you went to that showed your weight helps..
and of course any co- moralities
Good Luck !! Deb
Most Active
Recent Topics
