RNY to DS appeal help

[KittyMom2]

Hello all!

Just wondering if any of you have been successful at getting your insurance to pay for RNY revision to DS? I just recieved my first denial. The only reason they are stating for denial is that it is not "medically necessary" despite my BMI of 56 and several co-morbidities. With RNY I was never able to get out of "super morbidly obese" category or off any medications. They did state in the letter that they will continue to cover "alternative" treatments such as nutrition and behavior. Do I have a leg to stand on to appeal?

Does anyone have any sample appeal letters? Or any scientific studies that you recommend I refer to in my letter?

I greatly appreciate any and all suggestions!

 

[Larra]

The first step is to get your EOC (evidence of coverage) to determine what your insurer covers for revisions, if anything, and what criteria they require to be considered medically necessary. This is a LONG document, like about 100 pages, not a summary of benefits. You may be surprised how hard it can be to get your hands on it, but without knowing your policy, you are just guessing about how to appeal, or even whether or not you have appeals rights. You can get this from HR, or, if insurance is through your spouse's job, though spouse's HR. Be prepared to run into lots of ignorance and need to speak with supervisors.

 

[KittyMom2]

The first step is to get your EOC (evidence of coverage) to determine what your insurer covers for revisions, if anything, and what criteria they require to be considered medically necessary. This is a LONG document, like about 100 pages, not a summary of benefits. You may be surprised how hard it can be to get your hands on it, but without knowing your policy, you are just guessing about how to appeal, or even whether or not you have appeals rights. You can get this from HR, or, if insurance is through your spouse's job, though spouse's HR. Be prepared to run into lots of ignorance and need to speak with supervisors.

Hi Larra!

I have my handbook (about 100 pages) and "summary of benefits" and the first page of the handbook says "this along with the summary of benefits makes up your evidence of coverage." Does that sound accurate?

 

[Larra]

It might be. Please start a private conversation with me and @DianaCox so we can take a look along with you and see where you stand.

 

[duh_Mom]

@KittyMom2 if it can be done these 2 ladies will get it done! their knowledge is amazing.