Wishing & hoping & dreaming & praying

[Rain 0]

Hi Lbers!

Here's my story and I'm sticking to it.

This is my second attempt to get approval from my Insurance company for lap-band® surgery. My first attempt was met by nothing but No's except from my wonderful primary care physician.

• I was told by my insurance company that any and all weight loss surgery was specifically denied in my policy.
  
• I was told by the lap-band® center that they no longer helped a patient to get coverage from an insurance company if their policy specifically stated the surgery was prohibited.
  
• My financial situation was horrible and there was no way I could afford cash-pay since as far as getting a loan, fuhgetuhboutit.
  

But this time, things seem to be happening just the opposite. Mind you, I am still in limbo waiting on approval but at least things look good . . . so far.

• While my insurance policy still specifically states that weight-loss surgery is non-covered, I was told by their Customer Service Rep that I could send a request from my doctor to their appeals department.
  
• My still fabulous primary care physician wrote another letter and this one was even more severe than the last regarding my need for surgery. Of course, my health is worse but still, the letter even had me gasp at the seriousness of it.
  
• Next, I got a copy of their response to my doctor asking for further information. This had me excited merely because at least it was not a curt "NO!" The information they needed could only be answered by a lap-band® surgery center.
  
• So I contacted the same center that I did previously but this time they sounded more than happy to help.
  

I had to go in for a visit, of course, and refill out my paperwork since my previous file had been destroyed. However this time they were exceptionally helpful AND they were told by my insurance company that the surgery might be covered if it was determined to be medically necessary.

On a down note, the lap-band® lady did imply that my insurance company was notorious for saying one thing on one call and something different on another. Still, it was something positive and at this point, I'm hanging onto what I can.

Is there anyone else out there whose insurance company said the surgery was specifically denied in the policy but they allowed it anyway? Please someone give me some more hope.

[serenity55 15]

Rain, I know exactly how you must feel.

When I started my lap band journey, I was told that coverage for lap band surgery wasn't specifically mentioned, whatever that meant. But in my case, it was the medical group that kept denying me. I took two psychological evaluations, saw two cardiologists, wrote letters for everything they denied me for--with the help of my primary care physician.

The second psych evaluation and cardiology appointment were after I'd been approved, and that only happened after my medical group was bought out by another one.

I truly wish you the best of luck. Please let us know what happens.

Debbie

[sparkplug 106]

I was turned down TWICE by my insurance even though it is a covered expense. I refused to accept their decision. Even though I only needed to lose 90 pounds, I have high blood pressure, high cholesterol, borderline diabetic and knee and foot problems, they still gave me a hard time. I refused to give up and got approved on 12/08 and had surgery on 12/20/08. I am to goal with losing 90 pounds, and I am saying DO NOT GIVE UP YOUR FIGHT TO GET THIS, you will never regret it. Good luck and keep fighting them until they get sick of hearing from you and give in to your demands, lol. It worked for me, hopefully they will see you really mean business and will give in.My primary care physician helped me a lot with his letter to get this surgery.