Reimbursement

cyabob · May 2, 2004

Has anyone had any luck getting an insurance company to reimburse a self-pay? My insurance company (Aetna) had very restrictive guidelines for lapband so I wnet ahead and self-paid. Two day after my surgery, I recieved an approval for gastric-bypass from Aetna. Gastric bypass was not the right surgery from me so no great loss.

I would like to get some reimbursement or at a minium coverage for fills, etc.

What do you think?

GeezerSue · May 2, 2004

From the Aetna Policy Bulletin:

...Aetna considers any of the following laparoscopic procedures experimental and investigational because the validity of their effectiveness has not been established in prospective, randomized studies with long-term follow-up:

1. blah

2. blah

3. blah

4. Gastric banding for morbid obesity, including laparoscopic-adjustable silicone gastric banding (see CPB 157 - Obesity: Surgical Treatment)

5. blah

6. blah...

So, since their only grounds are the incorrect claims above, then I'd contact Don Mills at Inamed and Walter Lindstrom. Someone, somewhere on another board was reimbursed by a company. I don't recall which or why, only that they did collect after the fact. And that was before there was good research, so I'd think you have a better case.

Good luck,

Sue

Alexandra · May 2, 2004

Hi Bob,

I have lots of experience with Aetna. They've relaxed their policies somewhat with regard to banding, so if you were a self-pay here in the States you certainly can try submitting your costs for payment. You were diagnosed with MO and Aetna has agreed to pay for surgical treatment. So you've already won that part of the discussion. What you will have to convince them of is that RNY was medically contraindicated for you--that there were good MEDICAL reasons why that surgery was wrong for you.

(If you were banded in Mexico you're probably completely out of luck: Almost all carriers say in their contracts that no coverage will be extended for non-emergent medical care received outside the U.S.)

I do think you might be able to get your fills covered either way. Adjustments are medically necessary followups to surgery, without which you will continue to suffer from a condition for which treatment is covered. See if your doc will submit a precert request for an adjustment. Then see what Aetna says.

Good luck, and please keep us posted!