GinaB

:help: I Just got home from Hospt. from having Lap band surg. I heel like im not getting enough nutrition in me. I know im on Clear liquids but im barly getting 100 cals. down a day. can someone tell me what there first few days where like as far as eatting. Im also alittle unsure of hom much i sould be drinking at one time because its taking me ten to fifteen min. to get once ounce down.... is that normal? Im up and walking but it feels like a horse is sitting on my chest the pain is at a five out of ten.....How long untill I see light at the end of the tunnel. any :help: would be great thanks in advance Gina B.

No, it's not a river. It's longer, deeper and the waters are much muddier When I’ve just about lost all hope a tiny ray comes shining through. Yesterday after noon I received a call from my insurer (Highmark BC/BS). It was a girl telling me that she had my appeal and needed to go over a few things. I didn’t understand why SHE had my claim because the last appeal I made was to my employer (Alcoa). She said that Alcoa had contacted her because I had appealed to them in error. The appeal, at that stage, was supposed to be made to the insurer. The timeline went like this…..My doctor filed my initial paperwork. It was denied. :cry With that denial were instructions on how to appeal to Highmark. I appealed and was denied again. :cry :cry This appeal has no instructions on the next step so I called them and was told that I had exhausted my appeals with Highmark and now had to go to my employer. The proper paperwork was sent to me and I filed an appeal with my employer. This appeal, as it was explained to me, was IT. This was my final attempt at trying to get approved. Until yesterday I’d been waiting 2 weeks and still no word but I was told the process could take 60 days. Then I get this call from Highmark yesterday saying that I was really allowed 2 appeals with Highmark before going to my employer. I had been given mis-information and she apologized. We spoke for quite a while and she really listened and took the time to hear me out. She said that I had a choice of using my 2nd appeal with Highmark or going straight to my employer. However, if I waived the 2nd appeal and my employer denied me, I couldn’t go back to Highmark. I expressed to her that I didn’t see what good it would do to appeal to Highmark again. Highmark denied the doctor once and me once and both times for the same “experimental/investigational” reasons. She encouraged me to try again. She told me that the first level of appeal went to the medical review board and this current appeal would be seen by an appeals committee. She said that they review appeals in a very different way and look at things that the medical review board wouldn’t. She said that at least if I was denied again by Highmark I would still have another chance up my sleeve with my employer. She really encouraged me not to give up and to use this 2nd appeal. It was like being given a second chance as spinning a wheel to win a million dollars. She even gave me her direct number and told me to call any time. She is going to expedite my appeal and tell them it’s a high priority appeal. She really wants to see this approved by the end of the year because I’ve met all my deductibles . So, there it is in a nutshell. I’m really trying not to get my hopes up too much but I just have this feeling that this time it’s going to be approved. I have to say it was just nice to finally speak to someone from my insurer that was sweet, kind, considerate and seemed genuinely interested in helping me.:biggrin1: All of you out there who are waiting and hoping, I’m right there with you. I know how depressing and frustrating it can be. Please try not to loose hope. You never know what the next phone call might bring. Take care everyone, Gina B.

ERISA is ..well, I don't know what to call it. It's, as best as I can describe, a federal law that governs companies who self fund their benefits programs...like my employer. Well, as you have read in my previous post, Highmark BC/BS has denied me 2 times. Because I live in MASS I have Highmark but if I work for my company and lived in CT (1/4 mile down my road) I would have Cigna. Our companies Cigna plan covers this procedure. It's in black and white in the policy guidelines and coverage position. Within the ERISA's wording are guidelines that all self-funded companies have to obide by. One is that "similarly situated" employees must be offered uniform benefit and no discrimination is allowed. I think this may be where the light is peeking through the clouds. I pay EXACTLY the same amount each month as my co-worker who lives in CT. However, she has Cigna and can get the operation and I don't. Doesn't seem very fair does it. Well, Highmark is sending me the appeal paperwork to send in to my employer (2nd appeal) and I am going to mention ERISA and see what happens. I'm not sure if I'm interpreting it correctly but I don't think I'm too far off the mark. We'll just have to see what happens. Is anyone out there fighting a denied claim against a self-funded employer? Just wanted to know what everything thinks about my theory. Thanks, Gina B. PS....I got the ERISA info from the Gov't website and was directed to it by an article I saw about Harrahs finally covering Lap Banding

Well, I have been denied a 2nd time by Highmark. I submitted over 40 pages of medical information and citations and they said they still won't cover it based on their stance of "investigation/experimental". They said they have only covered one other company and that's the Railroad workers. I have no clue what they did but I need to find out. I but they bought a rider for their policy and now it's covered. Now I appeal to my company. We'll see how it goes. I am absolutely not giving up and I'm NOT getting bypass no matter how much these insurance people push me towards it. God, I am just so sick of this never ending battle!!!! It almost feels hopeless but I just have to stick with it. I see folks on here that battle for 1 year or more and finally get what they deserve. I wish you all better luck then I've had!! Gina B.

Mandy: I have been had my employer involved since day 1 of the denial back in April. They haven't been of any real help. They say they see the difference but don't really say what they are going to do about it. I am the HR assistant at the location I work for and this is my email communication between me and the corporate benefits specialist. Can you read it and see what you think they are trying to say? To me they are just saying "Yup, we see the difference but you are going to have to bark up the Highmark tree and not ours". Thanks for reading...sorry so long. ****************************************************** Hi Gina, Alcoa Benefit Services reviewed the communications from both Cigna and Highmark. Its has been decided that you should file your first level appeal with Highmark as indicated in the letter dated 4/25/2006. We can see the differences between both Cigna and Highmark. Cigna stating approved procedure based on criteria met, and Highmark stating not approved because procedures are considered experimental/investigational. There should be clear and concise information that supports what is consider experimental/investigational. I would suggest submitting Cigna's Coverage position with your appeal. Lynda: Thank you very much for getting back to me. I am compiling my first level appeal letter packet this week and mailing it to Highmark. Since I have now completed the 6 months of nutrition that was requested in the denial letter, I just have to prove to them that the procedure is not experimental/investigational. Not an easy undertaking I'm afraid. I'm told from Inamed, the makers of the Lap-Band, very few people have been able to overturn a denial with Highmark that was based on the experimental/investigational stance. Highmark is one of the last hold out insurance companies not covering the band. That said, I did want to mention that what I'm most confused about is that fact that the policies vary. The fact that coverage isn't uniform between policies within the same level of coverage seems unfair. Maybe I am not clearly understanding the "self-insured" aspect of our policy. If I am an employee that has chosen Coverage Level X and I live in Mass, shouldn't I have the same coverage as a person with the same plan who lives in CT? If so, that's not how these plans are working. If I lived in CT, this would be a moot subject because our Cigna policy covers Lap-Banding. I was told by both Highmark and Cigna that Alcoa determines what is and is not covered. Highmark does not cover Lap-Band as a rule due to their medical review boards determination that the surgery is investigational/experimental, however, their rep told me that all Alcoa has to do is to tell them to cover it and it would be done because, being self insured, Alcoa determined what would and wouldn't be covered in the first place. Could you please explain why the differences exist? Thank you. Gina Breen Hi Gina, I certainly understand your point. I must tell you Alcoa does not decide what is covered and what is not. Alcoa purchases a plan from Highmark and what is covered is based on medical necessity as well as procedures that are considered approved by the FDA. I do agree that we should not be seeing differences in benefits offered under Cigna and Highmark, having said that, I hope that your appeal points out the differences between the two carriers. Keep me posted. *******************************************************

I have posted a few times about the issues I'm having with my denial from BC/BS. I work for a company who is headquartered in PA so even though I live in MASS and work in CT, my insurance is HIGHMARK BCBS OF PA. My denial sound about the same as yours. The denial letter states: that I am not eligible for reimbursement because the” surgery has been determined not to be medically effective for the condition being treated and therefore is considered experimental/investigative in nature” It goes on to say that a procedure is considered to be experimental/investigative if: The intervention doesn’t have FDA approval to be marketed for the specific relevant indications;or Available scientific evidence does not permit conclusions concerning the effect of the intervention on health outcomes; or The intervention is not proven to be as safe or effective in achieving an outcome equal to or exceeding the outcome of alternative therapies; or The intervention does not improve health outcomes;or The intervention is not proven to be applicable outside the research setting. I was then provided with the medical policy bulletin that states: There is a lack of peer reviewed medial literature that contains comparative data that demonstrates that Lap Band is equivalent to or offer any advantage over the accepted standard of vertical banded gastroplasty or Roux-en-Y gastric bypass. ************************************************************* Does that pretty much sound like your letter? They will give me RNY surgery on any day of the week but Lap-Band is a NO GO!!! I was also denied because I needed 6 months of nutritional and excercise consulations that were overseen by an MD. I have finished those and I'm also continuing to go just in case 6 months suddenly changes to 8 or 9 months if they deny me again. They are very underhanded these people. I am formulating my appeal and will have it ready to go out by the end of this week. There primary issue is that they feel that RNY is more effect and the gold standard surgery. I am attaching with my appeal all sorts of research that comes close to challenging that assertion. I have to admit that in all my research I never came across the sentance "in conslusion, we find Lap-Band to be equally or more effective for the treatment of morbid obsitity then RNY". I would've loved to..but I couldn't find anything. So, I will appeal, keep my fingers crossed and then....if that doesn't work....I'm changing my address and getting differnt insurnace. The kicker of all of this is that if I live a 1/2 of a mile down the road in the state of CT my employer would have me covered under CIGNA and our CIGNA plan covers Lap-Band. Yup...I just don't get it. I am paying the same amount of money as the person I work with for the same coverage but I have Highmark and she has Cigna and she is going for the surgery and I'm not. It really is enough to make me want to cry. I really wish you the best of luck and hope that we can both finally get what we so badly need, deserve and want.....a life free of being morbily obese!!! Take care, Gina B.

I received a denial letter from Highmark BC/BS on March 25th . I was denied because they deem the band procedure as experimental/investigational. They contend that RNY is more effective and has better long term results…yadda, yadda. It’s nothing that we haven’t heard on this site a million times before. Since my insurance company is self insured, I have been fighting with my HR department, to no avail, to get the policy changed. What is so outrageous to me, is the fact that if I lived in a different state (5 miles from my home) I would have Cigna and the policy would cover it. I happen to live in Mass and therefore my company offers Highmark BC/BS to people in MA. Highmark is a Pennsylvania based insurer. My company, Alcoa, is headquartered in PA. So, the bottom line is, if I lived in CT right now I would be banded and all this denial BS would be behind me. So, now that I’ve rambled in frustration…..let me get to the point. Does anyone have documentation or anything that supports the use of Banding over RNY? I know that this is the type of information that will help me with the appeal. Any info would be terrific. Thanks in advance.