Appealing a Denied Prior Authorization
In the event you are denied, do not become upset. This is common and often a “first response” by many insurance providers. Unfortunately, many individuals face this challenge when getting approved for weight-loss surgery. However, it is important to know that you can appeal this decision and let your voice be heard.
It is essential you understand the appeal process prior to you submitting your appeal. It is also important that you construct your appeal carefully, making sure that you provide support for each reason you were denied. Typically, your surgeon’s office will submit the necessary information to appeal your denial. If they do not, you can appeal it on your own. How you appeal your denial depends on the type of plan you have (fully-insured or self-insured).
If You Have a Fully-insured Policy
The next step is to resubmit the authorization. For the resubmission process, you will need to know why you were denied. Do not be afraid to call your contact and ask for a detailed explanation in writing as to why you were denied.
Once you receive the explanation, read it carefully. Most times, denials are categorized as either “Not Medically Necessary,” “Experimental Procedure” or “Excluded Procedure.” If there is something in it you do not understand, call your provider and ask for a more detailed explanation. Remember, you pay for your insurance, so let them work for it. Review your billing codes and make sure the correct ones were used.
“Not Medically Necessary” Categorization
In the event the denial was categorized as “Not Medically Necessary,” make sure the correct codes were used and then request a letter from your doctor stating the nature of the procedure. Once you have the correct codes and a letter from your doctor, resubmit (Please click here for a sample letter).
“Experimental Procedure” Categorization
In the event the denial was categorized as an “Experimental Procedure,” make sure the correct codes were used and then request a letter from your doctor stating the procedure is not experimental. Once you have the correct codes and a letter from your doctor, resubmit (Please click here for a sample letter).
“Excluded Procedure” Categorization
In the event the denial was categorized as an “Excluded Procedure,” once again, make sure the correct codes were used. At this point, make sure all factors of your severe obesity status have been reported, such as co-morbid conditions that affect you (heart disease, diabetes, sleep apnea, etc.). Once you have the correct codes and a letter from your doctor stating your current health condition (including all co-morbid conditions), resubmit (Please click here for a sample letter).
Some insurance providers are limited by the state in which they operate as to the number of appeals they can accept from patients. If you have reached the maximum number of appeals from your insurance provider, you may be eligible for an external review.
If your state offers external reviews of denials, you have the right to request a review of the HMO’s decision concerning the complaint or appeal within 365 days after receipt of the final decision letter from your insurance provider. For a definition of External Review, please see the Glossary at the end of this guide.
If You Have an Employer’s Self-insured Medical Benefits Plan
The denial probably will occur at the predetermination stage of the process; therefore, you may not receive a formal Explanation of Benefit (EOB) form from the provider denying the authorization. In order to submit an appeal, you must receive a formal written denial, usually in the form of an EOB. This EOB should include a paragraph explaining your appeal rights and how to submit an appeal. Such as:
If you do not agree with this determination, you may appeal it in writing to the Pension and Benefits Appeals Board within 60 days of receiving this letter. In addition, you have the right to appear personally before the Board, review pertinent documents, submit issues and arguments in writing, have a representative appear before the Board or present written issues and arguments, and present additional information to the Board.
The denial should also give you a detailed explanation why you were denied, and what specific sections of the plan were used to make the denial.
Do not be afraid to contact the provider to request the details of your denial. Also, if you have studied your plan and feel there is a specific portion of the plan that allows for the treatment, you should ask them to review your denial with this in mind. Many times an insurance company applies the rules they have for their insured products and not the plan rules for the specific employer when making initial determinations.
The laws and regulations that allow a company to get tax advantages for providing employees with medical benefits also require the plan to implement an appeal process. A verbal denial, such as the plan does not cover this procedure, does not meet these regulations. If you cannot get a formal denial from the provider, contact your employer’s personnel or benefit department for a formal denial. At the most, the plan must respond to your claim within 60 days or they may not be in compliance with ERISA.
Once you have received the denial, you should submit your appeal paying close attention to any time limits required by the process. This may sound like a lot of work, but in the end the benefits to your health are worth it.
The process of contacting and working with your insurance provider may be a frustrating one. Do not become discouraged. By taking your time with each step and maintaining patience, you will only enhance your ability to have your treatment option covered by your insurance. Remember your rights as a policy holder. Do not be afraid to ask questions and do not forget, as we mentioned before, that you pay for your insurance, so make them work for it!
Statistics to Include in Your Appeal Letter
These statistics briefly detail morbid obesity and its affects in the United States. Feel free to use these statistics when writing your letter(s) to your insurance provider. Educate them on the affects this disease has not only on you and your quality of life, but also others.
- It is estimated that more than eight million Americans are affected by severe obesity. Morbid obesity is characterized by an individual weighing more than 100 pounds over their ideal body weight, or having a body mass index (BMI) of 40 or higher.
- Approximately 75 percent of those affected by severe obesity have at least one co-morbid condition (diabetes, hypertension, sleep apnea, etc.) which significantly increases the risk of premature death.1
- Life expectancy for a 20 year-old male with severe obesity is 13 years shorter than a normal weight male of the same age.2
- Annual direct medical expenditures attributable to obesity are $147 billion.3
1. Must A, Spadano J, Coakley EH, Field E, Colditz G, Dietz WH. The Disease Burden Associated with Overweight and Obesity. JAMA, 1999;282:1523-1529.
2. Fontaine KR, Redden DT, Wang C, Westfall AO, Allison DB. Years of life lost due to obesity. JAMA. 2003 Jan 8;289(2):187-93.
3. Finkelstein EA, Trogodon JG, Cohen JW, Dietz W. Annual Medical Spending Attributable to Obesity: Payer – and – Service – Specifics Estimates. Health Affairs Web Exclusive, July 27, 2009.