Denied... what do I do now?!

[PinkFish 1]

I'm so irritated! I saw my PCP back in May and she put through a referral for the lap-band®. I got a letter in the mail in early June, instructing me to fill out an online questionnaire for the program, which I did right away. Just now I received a letter from the program saying that my insurance requires me to have a BMI greater than 40 and at least TWO co-morbidities. My BMI is 47 and my PCP documented that I have joint pain and psychological effects from being overweight, but I guess neither of those two issues count, because I was denied. One thing that irritates me about this is that the speaker at the lap-band® seminar said that the social workers in the program will work with you in any way possible to come up with ways to get you approved, yet the denial letter stated that my "account" was being deactivated and basically good luck losing weight without us! Thanks a lot.:thumbup:

Anything I read about co-morbids usually says "Sleep apnea, hypertension, diabetes, etc.." but it never gives any ideas as to what the "etc" could be.

I'm so upset that I was denied and it makes my weight loss goals seem impossible to reach now. I feel like giving up, but I can't. I don't know where to go from here or if I should even bother with WLS anymore. Any advice would be greatly appreciated.

[losethemess 14]

I got the most accurate information from my insurance company. Try calling them and asking for a different doctor referral. Are you sure that you insurance covers lap band surgery? If so with a BMI of 47 you should be approved. Try going to a doctors office that is more helpful and knowledgeable, that makes all the difference.

[BetsyB 9]

Your insurance policy is what you need to focus on. If you don't meet their requirements, then ...you don't meet their requirements.

A doctor's office can only do so much, in terms of "creating" comorbidity. Joint pain and psychological effects of obesity are not among those covered by my insurance.

The place to focus your attention is your HR department. They have the ability to request changes in the policies they offer employees. You may have to wait until they are next negotiating contracts to get approved--but between now and then, you can make a lot of noise so that they DO make this request.

Fact is, with a BMI of 47, comorbidity will ultimately cost your employer health dollars. You can make a strong argument for them to change their requirements. (It's their decision; they chose the coverage based on $$--they thought it would be cheaper to restrict bariatric surgery; you need to convince them that in the long run, it's not.)

Failing that, is there another health plan they offer? We have the choice of a handful---and have a window, each year, during which we can switch.

If so, read ALL the policies to find which is most favorable to you, in terms of approval for the surgery you want.

[btrieger 21]

If it's some fly-by-night Lapband group that "deactivated" and denied you; don't fret it. There are thousands of competent surgeons out there that will really care about you and your health. Not just your wallet.

Click "Surgeons" on the top of this page and find one in your area. Give them a call and find out if they are in your insurance network.

[Lady Lap Band 71]

Ironically I got this info today via email from Allergan today...hopefully it helps you out!!

______________________________________

Dear LAP-BAND® System Patient Advocacy Council Members,

I hope that everyone enjoyed a relaxing holiday weekend with friends and family.

My plans are to send you monthly information with the hopes that you share it with others for their education. I truly believe that together we can make a difference in the lives of many.

Did you know that most LAP BAND® cases are covered by insurance?

The reason for the question is it’s one of the biggest concerns that we hear from people who are thinking about the LAP BAND® and it can be a deciding factor in moving forward with the procedure. Perhaps you’ve seen our television commercial that addresses this very subject. “Think the LAP BAND® procedure is too expensive? Well, that’s what many others have thought - before they found out that insurance covered it.”

That’s right. Many insurance companies do cover the procedure and you can find out if yours is one of them fairly easily.

So how do you find out if your insurance company will cover it and if you qualify for the procedure? As always, it’s best to verify your coverage directly with your health plan carrier. So, call them today and ask.

Otherwise, as part of our website, and once enrolled in My Lap Band Journey, you’ll have access to an online tool that will do a preliminary screen to help you determine whether your insurance will cover the surgery. To check out the new insurance tool, please visit http://lapband.com/en/lapband_is_for_you/costs_payment_options/financing_surgery/. Additionally, the LAP-BAND® Reimbursement Hotline [1-800-LAP-BAND (527-2263), Option 3] is a great option that letsyou speak live with an experienced professional about insurance verification related to the surgery. Hotline hours are Monday through Friday, 6 AM to 5 PM PST (9 AM to 8 PM EST).

What if they don’t cover it? What can you do then?

One option is to appeal your case. If your request for prior authorization for the LAP-BAND® System surgery is denied by your insurance company, you may have the opportunity for a limited number of appeals of this decision. The process varies according to the plan, so be sure to check your insurance company's specific appeal policy. Generally, you can appeal if your denial is based on the following reasons: The LAP-BAND® System is investigational, The LAP-BAND® System is experimental, or the insurance company has no previous knowledge of the LAP-BAND® System. The LAP-BAND® website has several downloadable resources to help you with your appeal, including: a patient guide to insurance appeals and a sample letter of medical necessity. These documents can be found at http://lapband.com/en/resource_center/.

Another option is to finance the procedure. If your doctor is a participant in the LAP-BAND® System Patient Finance Program, you are eligible to apply for CareCredit®, which is the nation’s leading patient financing program. If your doctor is not a participant, he/she can easily enroll in this program by contacting his or her LAP-BAND® System Account Manager. CareCredit® provides a choice of convenient monthly payment plans designed to help patients pay for healthcare expenses not covered by insurance, including co-payments, deductibles, and elective treatment. Upon request and approval, CareCredit® can help cover medical fees. Patients can choose from two types of payment plans: Low-Interest Payment Plans or No-Interest Payment Plans. To learn more about the CareCredit® program for LAP-BAND®, please visit http://lapband.com/en/lapband_is_for_you/costs_payment_options/financing_surgery/.

As always, we welcome your feedback and look forward to hearing if you and your readers found this information helpful.