No Sleeve For Me

[Gigi_Girl 77]

Thought I would give everyone an update. Insurance won't pay for a "second type" of surgery. My Realize band has a leak and insurance company, BCBSAL, agreed the band malfunctioned and wrote, pending the physician's request, they would approve to reband me. They had already approved the band to be removed, but I wanted revision to return to the restriction I once had. (Doc removed the remaining Fluid when I was having an Upper GI in mid April.) If the doc's office can get an approval letter to reband, then that is the route I will take. I suppose if this one fails, I can always choose to pay for the sleeve.

My choices:

Remove the band

Remove and replace the band

Self Pay for the band to sleeve revision

Good luck to everyone else on the sleeve journey. I'll keep an eye on your progress.

Gigi

[ChristyLove 39]

I am sorry. I too had the band and I am waiting for the approval from the insurance company

[PEvette 297]

I would see if you can get the insurance to cover the unbanding and pay for the sleeve out of pocket....so you will not have pay for hospital and what not

[Pookeyism 1,143]

I would see if you can get the insurance to cover the unbanding and pay for the sleeve out of pocket....so you will not have pay for hospital and what not

That is an excellent idea. Actually, no matter who pays, the manufacturer or insurance, they can't tell the surgeon that he cannot do a sleeve. Just leave the sleeve part out and make arrangements to have the band removed - and discuss the sleeve with the doc and pay for that.

It is definately worth it to pay for the sleeve on your own, btw...

[aldmb2 24]

Have you tried an external appeal??? I just got my approval today from the external. Yes, it was a long process that took months. But, after the tears shed, & a 57 page appeal letter it worked.

[Gigi_Girl 77]

Pevette and Pookeyism, Yes, I have heard of "upgrading" surgeries from others. In plastics, often insurance will cover a panneculetomy, but surgeons will charge the patient the difference to upgrade. I have hounded the insurance coordinator from a variety of angles attempting to get a price for the difference of the band removal and revision to sleeve. I am more than willing to pay a fair difference. I was told that it was fraud to submit on procedure code to insurance when in fact another was performed. They refuse to do it.

Maybe someone with insurance filing experience can explain this to us?

[Gigi_Girl 77]

Have you tried an external appeal??? I just got my approval today from the external. Yes, it was a long process that took months. But, after the tears shed, & a 57 page appeal letter it worked.

I have made two appeals to the review board in this six week period. did your insurance state only one "type" of weight loss procedure in a lifetime?

doc and I presented medical issues with the band and the leakage problem. They agreed to revise, but only to band. What on earth did you put into a 57 page appeal?

[PEvette 297]

You probably need to find another doctor's office, someone who is willing to work with with you.....that's not fraud, they approved the band to be removed...the surgeon bill them for that....and bill you for the sleeve....

How is it that people who have rotten insurance (like me) get hernia repair and pay like 6,000 more for the sleeve procedure because their insurance doesn't cover it??? That's not fraud, the surgoen is billing for what he or she did and getting the rest from you...

[aldmb2 24]

Well, I was denied (after the 6 months of hell) because my BMI is under 50. My insurance stated it was not 'medically necessary". I also had the 2 denials from the insurance through their appeal process. When I got my 2nd denial letter there was a part stating that I had the right to an external appeal. So I personally wrote 15 pages on my own siting various sites ( even my own insurance companies site), showing that it IS medically necessary. The other pages were all my medical history, notes from my surgeon, dietitian, Pysch Eval, and multiple works cited. It was like being back in college. I just got word today that the external appeal party has found it medically necessary. Now, he did tell me this doesn't mean the insurance has to pay for it, but most companies dont want to deal with a lawsuit. External appeals are done on a Federal level.

[Gigi_Girl 77]

aldmb2, my frustration lies with insurance saying the removal is medically necessary...but they choose what to revise to same procedure. As you said, external reviewers can't make insurance companies pay.