emergency surgery covered, replacement DENIED

[luv2laugh 0]

After having a barium xray swallow and showing my stomach prolapsed up through the band, I was scheduled for "must-do" surgery.

Got a denial for $14,000:eek: (plus $3,000 from anesthesiologist) for everything.

Doc sent an appeal saying it was an emergency, had to be done, couldn't live with the band that way, etc... Also stated I had been slowly losing, until the surgery, and now that I'm not at my sweet spot, has gained a couple pounds. This basically shows that I NEED a working lap-band® in me to keep from gaining the 90 lbs I had lost.

Well, now they approved the removal, but DENIED the replacement band. Apparently, my bmi is 39.9 (needs to be 40 to be covered or between 35-39.9 with a co-morbidality) and I'm too SKINNY for the replacement band to be covered.

Doc is putting in a 2nd appeal. For some reason the hospital and anesthesiologist never sent their own appeal (I thought the doc doing it was enough, but it isn't).

What do I do? Is my credit going to get all screwed up? The $14,000 bill from the hospital was 30 days overdue on Dec 5th... I called and told them we have asked for an appeal.

My husband and I are beside ourself. I am scheduled for a fill on thursday, but I don't want to go because I don't think they will cover that either! The good news is my new insurance (BCBS PPO) starts Feb 1st, and I think fills should be covered because it's a medical device that's already in me?? (but there is a $1500 deductible per member, and $3,000 per family) My current insurance is United Healthcare.

Any suggestions? Do I need to hire a lawyer?:rolleyes2:

Oh and the total kicker is the hospital didn't weigh me the day of surgery... they asked me how much I weighed.. I said 217... (last dr's visit").. However, it was more:unsure: (since I got unfilled because I couldn't swallow my own spit. then I could eat more), but I said the lesser number because I didn't want my surgeon to be upset that I gained a few pounds ...

Brenda

[luv2laugh 0]

Just an update -

Insurance FINALLY paid the bill ($21,000 total) after multiple denials, and doctor sending new requests for coverage.

Most insurance companies just keep denying patients hoping they will give up. DON'T - keep fighting, cause in my case, we won. :thumbup: WOOOHOOO!

[mominkansas 2]

Did they pay for the replacement as well?

Your post hit home for me. I also have UHC and had a prolapse. I meet with my doctor tomorrow to look at my options.

[luv2laugh 0]

Yes, they finally paid for the removal AND the replacement after multiple denials, and asking for more information. The total ended up being $21,000. I even sent them a fax with everything I went through explaining that I had to have it put back in or I would gain all the weight back, and end up back on high blood pressure meds, a c-pap, etc. In the long run, it would save them $$ by keeping me healthy!

Good luck with your appt tomorrow. I was contemplating doing a gastric sleeve revision, but my doctor had only done 1, and we didn't have enough time to get approval. So, I figured if the lap-band has another issue, I'll change it then.