After exhausting my appeals to the insurance company, I went through my state’s insurance regulator. The insurer fended me off for a while by treating it as a *coverage* appeal, but once I was able to force it to be treated as a question of medical necessity they ultimately caved. They even wrote up a very appropriate policy about covering it for other J-pouchers in the future. It took over a year and plenty of persistence. An evidence-rich letter from my doctor helped. I’ve posted all of this previously, including the letter and the insurance company policy, so a search on this site should turn up the details. Good luck!