Ok I had a initial review done by my insurance company to see if I could see Dr. Rogerson as he appears to be the premier expert in Wisconsin, and all the reports here were very positive.
DENIED!!!!!!!
Any tips on appealing this process, as far as info to provide.
The thing that would really help is an actual pier reviewed study showing the steep learning curve. The two doctors recommend by the insurance company had 30 and 40 resurfacings. From what I have read, I would be looking at a 4+% failure rate with that level of experience. Of course I need to talk to those doctors and find there actual failure rate. Will they give that info is asked? Are they required to?
Anything that would be helpful with an insurance review would be great.
Again I am an active 38 year old, 6’4â€, 230 pounds. I hope to be in the 210 to 215 range before surgery.
Mike
Hi Mike,
First of all, be sure to read your health insurance contract (yes, the long boring one) and make sure you follow the appeal procedures to the letter and meet deadlines as stated. You don't want to give them the chance to deny you on procedural grounds alone, which sadly they can and will. If there is a specific procedure for requesting a peer review, find out what it is and follow it.
The next question I have is did they give you any reasons, other than just flat out denied?
In drafting an appeal letter, it is helpful to include medical sources to support your claim. I know there is lots of information on this site regarding the learning curve, etc. that would be persuasive in an appeal letter. Just be sure to keep it factual, avoiding emotion.
I'm not sure you need to cite stats from the 2 doctors approved by your ins. co. but going with medically sound evidence from a reliable source will back up your asserstions. Another thought is to perhaps call Dr. Rogerson's office and see if they could possibly help. Never hurts to ask. On an appeal unrelated to this surgery, I asked my doctor for help in the correct terminology and procedures to include in my appeal, he helped and I won my appeal.
My final advice is to always mail any correspondence via certified mail with return receipt. That way you have evidence that you filed in a timely fashion and that it was received. Insurance companies will often try to deny whatever they can, if you are persist and question everything, within the context of the ins. contract, very often they will have to relent and allow it. It doesn't always happen that way, but you certainly never know unless you push them. They are usually betting that most people won't and quite often they are right.
Let me know if I can help. Good luck!
Denise