Let me explain with my current situation. I am 22 F and I currently weigh 305lbs.
I am obese. Morbidly obese.
Even though I have been trying for 5 years at this point to lose the weight on my own. Eat healthier, eat more fruits and veggies, cut out excess sugar, walk more, exercise more, the whole kit and caboodle.
But I still am not losing the weight. I am still very fat. And I am worried that it will cause very serious health problems.
So I talked with my doctor and she told me “We need to get you on a weight loss medication. Let’s try Ozempic”.
But my insurance told us that they don’t think I need the Ozempic so they won’t pay for it.
So we tried Wegovy and Mounjaro. But my insurance still rejected our requests.
They’re saying because I am young, and I am a diabetic with good numbers, I dont need the weight loss meds and I can just lose the weight naturally.
But ive been trying to and it hasn’t been working. So that’s why my doctor prescribed me the weight loss med.
Why is this allowed? Why is it that your insurance can deny you a medication, even if your doctor says you need it?
The insurance company is going to have a doctor who said you don’t need it. They will try to hide who that doctor is, specifically what their NPI is, which can be used to personally identify the doctor who made the medical judgement against your doctor’s without having to provide further explanation than they’ve already given. Depending where you are they may have to provide more information when directly asked for specific evidences, or will suddenly change their rejection on the claim with a letter from an attorney asking for specific details in writing. They know hiring an attorney is expensive and bank on people not advocating for their rights & people with severe medical issues not being able to afford to.
And lastly a video of a surgeon being denied the NPI of the insurance’s doctors who are likely breaking the law hiding behind the idea that insurance doctors are so hated they need to hide their identity even from other doctors to prevent reprisal. She was blacklisted from United claims for this video and others like it.
https://youtu.be/AZhCYisIQB8
To add on to this, my psychologist told me that he’s had antipsychotic meds denied by a urologist before, because the insurance companies often don’t actually care what field the doctor is in. All they care about is getting to say “a doctor” reviewed it.
And you can leverage that in your appeal letter.
Especially when you have a pissy provider who doesn’t like being told “no.”
I have a relative who is a doctor. Had a claim denied once from someone that was not a doctor. Next: denied by someone not actively practicing in the field. Then denied by a doctor with no experience in that specialty. Only after all of that was it approved. They’ve also been picky about order of operations, such as not covering an MRI because there wasn’t also an order for a CT.
then they have teams to review the first insurance agent approved your medications, and sometimes a team to review that teams decision of said medication. they will do this til you give up.
This is the lore. I haven’t heard from anybody trying it, I hope OP will make the attempt and report back.
Isn’t the insurance approving the medication/procedure only after being asked for proof the denial was legally obtained evidence that the denial was illegal, and reason enough for a lawsuit?
I have no idea, it might be worth checking with a couple attorneys who specialize in healthcare to see if you have a case worth pursuing as many will at least do a quick consult to see if you have a case without charging. The legal system is setup for wealthy people and organizations though so I wouldn’t expect much without something like practicing completely outside of their area or pretending to be from another state or something more than a lapsed certification or making judgements from a kinda similar but not really the same specialty.