State by State Lap-Band Surgery appeal rights link

[sue in ne 1]

Has anyone run into a denial after approval? I have a letter with an Auth # from the insurance Co. Then today, after surgery, they sent me a note saying it isn't covered ( all the bills from radiology, anesthesiology, and the surgeon )

(9K worth!!):hurray:

[roxie 0]

Has anyone run into a denial after approval? I have a letter with an Auth # from the insurance Co. Then today, after surgery, they sent me a note saying it isn't covered ( all the bills from radiology, anesthesiology, and the surgeon )

(9K worth!!):tongue_smilie:

Sue,

You need to call or write your states Department of Insurance or equal to, to find out their guidelines and regulations for this situation. Be sure to tell them that you have an authorization number, etc., the whole process from beginning to now and don't leave anything out. You should receive an acknowledgement of your appeal and an approximate timeframe for a decision. Good Luck!

[sue in ne 1]

All, Called the Ins Company on Monday- They do not pay the surgeons, etc until the hospital bill comes through and is paid. OK, but in the interim they sent me a note showing the cost of the services was mine- bad business process. The hospital billed and haven't heard , yet.

[basketma 0]

Kaiser So Cal is now approving this surgery but you have to do a song and dance for it. Check it out.. my husband who is an uncontrolled diabetic, hypertension, sleep apnea with cpap intolerance and a knee replacement in HIS ONE LEG could barely get approval- for the bariatric surgery.. I am now hoping for him to get the lap band instead, nevertheless me, also 100 lbs overweight but healthy-fergetaboutit. I was on a 12 step and lost 100 lbs, I kept most of them off, but I am still 100 lbs overweight and was starving the whole time I was on that plan. If I had a band I could stick with it. The sad sad part... I work for kaiser. truly disgusting. I now am going to the appeal thanks for the info, I should have remembered it from all the fun I had getting him the knee replacement - when reported, Kaiser suddenly stopped dragging their feet

Edited January 9, 2009 by basketma
extra info

[jtoler 0]

I can tell you the hospital I work at is a BAriatric center of excellence, it is not a rating given out very often as I understand it...the hospital is in southeast Georgia (Brunswick) SouthEast Georgia Health System the name of the physician group is georgia coast surgical (Medical Weight Loss Georgia :: Georgia Coast Surgical) good luck! I am just beginning the process and am sure I will be fighting AEtna...

[roxie 0]

I can tell you the hospital I work at is a BAriatric center of excellence, it is not a rating given out very often as I understand it...the hospital is in southeast Georgia (Brunswick) SouthEast Georgia Health System the name of the physician group is georgia coast surgical (Medical Weight Loss Georgia :: Georgia Coast Surgical) good luck! I am just beginning the process and am sure I will be fighting AEtna...

Hi All,

Your employer determines what your health benefits will be. The health plan only administers the benefits. So if your request for authorization is denied you need to contact your health plan representative, or Human Resources, where you work. Of course if your employer is the health plan then you would appeal to them. Make sense?

[monylove 0]

i am in a horrible position right know and i need som help or advice. I had my surgery in March and was approved and i just received a bill for over 25000.00 from the claims that they will not pay the bill. i went thru medical mutual of ohio got pre registered a week before surgery and was never told that i would be denied. I even recieved a letter from the medical board that it was a medical necessity to have the procedure done. Is there anyone who can help me withe som advice on how to get this paid. there has been people have this procedure done at work last year and not have these problems

[luvmy2dogs 2]

Hi, Why would your surgeon do the surgery without an approval letter. Do they have an approval letter. Check with your surgeon. Mine would not do the surgery at all without some kind of letter saying the insurance co. approves the surgery claim.

[sue in ne 1]

monylove, it gets confusing. i , too was pre-approved and my surgeon had the authorization in hand. But i, too had a notice from the insurance company saying they had to determine if they would pay the claims. I also got bills that were denied.

1st, pre approval means you meet the criteria for thie funding the surgery. Once the surgery is done, the insurance company will go over everything to assure the necessity is the same.

2nd, i found the physician's bills were being denied. It turns out all bills related to the surgery are suspended until the case is reviewed and they don't review it until the hospital claims come in. Sometimes the claims are denied instead of suspended. I had the surgery 12/1/08 and just got the final notice from the insurance company yesterday. Your time frame for this is about the same as mine. I think it is a poor practice to deny instead of suspend a biller and why don't they notify the biller ??

Do Call the insurance company and find out about the bills that were denied and what is their process. Also, your surgeon's office can help you appeal any denial. (but I don't think that has happened )

Edited May 1, 2009 by sue in ne

[gidgett 0]

Can anyone give me some advice...im stuck. I just applied for Healthnet and turns out they dont cover the lapband or ANY weightloss surgery. I dont have any money to pay out of pocket and I dont think I could afford the monthly payments of carecredit....HEEELP!!!!!

[sue in ne 1]

Gidgett, All insurance companies say they do not cover it t. But Most have criteria which if met, they will pay for the surgery. If you have a surgeon, check with his office.They deal with insurance Companies all the time . Ask here, esp in the Oregon groups. Sorry, I'm in NE and don't know your ins. Co. My insurance covered it in full. Others i know went to Mexico, cost was 2/3 of mine; even with the travel.

Edited August 28, 2009 by sue in ne

[49ermommy 0]

We have just added a new page to our site that will give you a complete list of each State and how to contact the proper Insurance Regulatory agency in each State as well as a brief outline of that State's rights. You'll note some States have external reviews, some do not. Each State is different.

Here is the link National Association of Insurance Commissioners (NAIC) State Web Map click state by state link.

Best of luck.

Gary Viscio

www.ObesityLawyers.Com

RNY 7/1/03

-165lbs

If my insurance company never game me the handbook disclosing the exclusion of my medical policy which include excluding anything that has to do with obesity and bariatric services, can I seek legal action? When I enrolled into my insurance with BCBS of MI all they gave me was a 2 page pamplet which listed the coverages and copays/deductables, one of which said outpatient procedures, I assumed that bc my lapband was an outpatient procedure it wld be covered, however after my dr called into to get approval they said that bariatric services was an exclusion in the policy, I am now dealing with my husbands employers benefits dept and they are referring me to the agent/broker whom we signed up with during the open enrollement, they are acknowleging the issue I have and are looking into what they can do but no one is getting back to me, does this sound like I might have a case if they decide not to change the policy to add bariatric services?:cursing: (any advice would help as im just trying to get this procedure bc it is medically necessary)

Thanks

Erika

[donna12 742]

Does anyone on here have Ky Access Ins? I currently have BCBS-Michigan that I've been on with my ex-husband and he had to pay for in the divorce for 18 mos. That will soon change, come June 30th it expires and I will have to get insurance. Due to my weight and height, 5'2" 285 lbs no ins company will carry me other than Ky Access. When I call them the only thing they tell me is "yes they cover Lap Band" but will not let me talk to anyone further regarding the procedure like do I have to wait 6 mos and do the required diet because BCBS waived that part because my BMI was over 50. I am trying to rush things along with my surgeon and get banded by June 30th, fingers crossed! But would appreciate any input from anyone on Ky Access???

Thanks,

donna

[Jessie88 0]

I live in WA and have Regions Blue Shield through my job at a hospital. Im 24, 5' 2", and too close to weighing 300lbs. Ive been informed by them that they do not cover anything to do with weight issues. They treat me as if I am this way on purpose. Obesity runs in my fathers side of my family and ive been overweight for as long as I can remeber. Ive dieted, excercised, taken every pill there is, and even resoted to anerexia and bulimia, but nothing has worked. Ive developed sleep apnea, high blood pressure, depression, and had to have surgery on my utetrus due to weight issues. I desperately need lapband because I just cant seem to lose any weight on my own. What can I do if my insurence company refuses to cover me?