Insurance Appeal

Insurance Appeals

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The Appeal Process

The majority of the insurance companies will include instructions to appeal their denial. Some will include the paperwork to use for the appeal. Some will suggest a telephone appeal. I would use a telephone appeal only as a last resort or if offered no other alternative, because you can more effectively present your medical information in writing. You will need to fill out their paperwork, but be sure to include a personal appeal letter (links to sample letters below). You should include your previous request for preapproval and all the paperwork that went with it. It is well worth it to ask your PCP to write another, more forceful letter. Also be sure to send copies of all medical records that support your co-morbidites especially recent records from any specialists treating you. This will help them see the serious ness of your conditions.

What to do When You Finally Get an Answer and it’s a Rejection

Be persistent. No, does not always mean no, never; it can mean no, not right now! You always have the chance to request and request and request. Often times after a second or third request that’s been denied it automatically goes higher. Don't give up until you have exhausted all levels of appeal.
Speak to your doctor. Your doctor and/or his office staff should be willing and able to telephone and follow up with a written letter to your insurance company to substantiate medical grounds for a reversal of the insurance company’s denial of your original request.
Appeal the decision to another level within the company. The appeals process may lead you to the very people responsible for setting policy about reimbursement for weight-loss treatments. Each health insurance plan may have several different levels of appeal. This can be a time consuming process, but don’t give up.
Contact your state's insurance commission in writing to describe your needs and difficulties. Send copies or summaries of your communications with the insurance company. Then, be sure to let your insurance company know that you've contacted the commission on your own behalf.
Write to state and federally elected officials who may be able to assist you in the appeals process. Update them on your situation and enlist their support on this important issue. Don’t forget about the Attorney General’s Office, the AG can be VERY persuasive!
Contact the Office for Civil Rights in your location. The OCR investigates written complaints of discrimination of the disabled under the American’s with Disabilities Act, in housing, public accommodations, the workplace and education. Morbid Obesity has been defined by the ADA as a qualified disability under the context of the law. Let your insurer know that you have filed this civil rights complaint—this may be just what gets good results.

Sample Consult Denial Appeal Letter

Sample Surgery Denial Appeal Letter 1

Sample Surgery Denial Appeal Letter 2