Stefanie S.
Well-Known Member
@Larra @DianaCox
Larra and Diana - I haven't wanted to bother you. It seems like you both just give and give, but if there's a chance you have a little more to give, would you mind helping me?
I got denied today for the 3rd time. Dr. Sudan did a peer-to-peer review today that he felt sure he'd win, but they denied me. My last chance is a self-appeal. I already had the surgery on Jan 24. Between my grandfather's help and some on my credit cards, it is covered. But they are also saying that anything related to this surgery, and any future complications will not be covered. Does that mean lab work? Does that mean if I have a life-threatening bowel obstruction or anything like that, insurance can actually refuse to pay? I have to fight
I've been reading responses you've given to others, so I've already requested my Evidence of Coverage from my HR department. I'll have to wait for my denial letter to come in the mail. I found this from Diana and I will work on getting these documents too: "We also need to see the actual written denials, the letter of medical necessity/request for preauthorization that was written by the surgeon, and a full copy of the bariatric policy that applies to your insurance plan. Revision surgery may or may not have a written requirement for a six month diet/exercise plan. We need to see what your appeal rights were in the denial, and in any case, who filed the appeal? You or your surgeon? We can't tell if the peer-to-peer was correctly denied without knowing what was said in the denial letter and the actual plan. Usually, the patient initiates the appeal, but you have to know what you're doing." And finally, I think @Mermaid is going to send me the letter you helped her to write.
I don't have the exact wording, but the denial is insufficient proof that I was compliant to my original sleeve surgery on Feb 10, 2014.
Open to any advice.
Sincerely,
Stefanie
Larra and Diana - I haven't wanted to bother you. It seems like you both just give and give, but if there's a chance you have a little more to give, would you mind helping me?
I got denied today for the 3rd time. Dr. Sudan did a peer-to-peer review today that he felt sure he'd win, but they denied me. My last chance is a self-appeal. I already had the surgery on Jan 24. Between my grandfather's help and some on my credit cards, it is covered. But they are also saying that anything related to this surgery, and any future complications will not be covered. Does that mean lab work? Does that mean if I have a life-threatening bowel obstruction or anything like that, insurance can actually refuse to pay? I have to fight
I've been reading responses you've given to others, so I've already requested my Evidence of Coverage from my HR department. I'll have to wait for my denial letter to come in the mail. I found this from Diana and I will work on getting these documents too: "We also need to see the actual written denials, the letter of medical necessity/request for preauthorization that was written by the surgeon, and a full copy of the bariatric policy that applies to your insurance plan. Revision surgery may or may not have a written requirement for a six month diet/exercise plan. We need to see what your appeal rights were in the denial, and in any case, who filed the appeal? You or your surgeon? We can't tell if the peer-to-peer was correctly denied without knowing what was said in the denial letter and the actual plan. Usually, the patient initiates the appeal, but you have to know what you're doing." And finally, I think @Mermaid is going to send me the letter you helped her to write.
I don't have the exact wording, but the denial is insufficient proof that I was compliant to my original sleeve surgery on Feb 10, 2014.
Open to any advice.
Sincerely,
Stefanie
