Denied because of only 1 WLS per lifetime.....

[Teachingmom 3]

My surgeon just submitted my 1st request & the office called to tell me it said it was denied because of the 1 WLS per lifetime. Am I screwed now? Is there any way to appeal that "clause?" Would the peer to peer help? Or would ANYTHING help? I am sooooo discouraged now- more than ever. My surgery is a revision to the sleeve because of an emergency band removal in feb. of this year. (Erosion & hole in my stomach)

[Teachingmom 3]

Additional note: my insurance is BCBS of Al. (Peehip- from the school system)

[TES 858]

I would think that you could appeal since the first surgery was not successful due to a defect in the band that affected your anatomy--and you have it documented.

[Teachingmom 3]

I will definitely try to go that route since apparently that's my only hope. But I'm pretty sure the office coordinator already sent that info in with the request. So what kind of info. Would we submit again? I will do anything necessary! Begging, pleading, crying....

[Tiny One 223]

You always have the right to appeal.

First, you need to review the list of exclusions for your plan. If your employer has it written in your policy to cover only one WLS, BCBS of AL must honor the benefits and exclusions as designed by your employer without considering medical conditions.

If its not listed as an exclusion, BCBS of AL would follow their clinical policy. Find out how the clinical policy reads. While it may say only 1 per life time, there may be exceptions based on medical conditions.

[Sassygirl06 962]

Appeal...appeal...appeal! The insurance company will try this stuff so they can pay the least amount of money possible. They are hoping for the weak patient that just sits there and takes a denial. Be your own advocate! Don't give up!

[Ms.AntiBand 2,984]

Seems like there was someone here who had the same worry. She was told that if she could not have the revision at the time of the band removal she was out of luck because only one per lifetime. Not sure how that turned out.

If your policy states only one they will fight you so they don't have to pay.. It I wouldn't give in. Sometimes you can beat them at their own game.. But if it's written in the policy, they have grounds to deny it

[Ruthie1974 34]

I had the exact same problem. I opted to pay out of pocket. Thankfully I had the band removed at the same time an that WAS covered, so my anesthesia and OR time was covered there as well. Also my insurance paid for the hospital stay and tests etc. They did not pay for the surgeon which was about 8,000. I would appeal, I think there is a book out there telling you what to say etc. Oh, and don't assume the surgery scheduler went above and beyond to get you approved. You can get insurance approval after denial it just takes longer and since you had the band and you had to have it removed due to complications you have a legal leg to stand on here. Good luck.

[Purplrose323 32]

You def have the right to appeal, but next year when Obamacare supposedly goes thru fully, I believe insurance companies are no longer allowed to have lifetime maximum clauses, or deny people due to pre existing conditions. So if the appeal falls thru there is always hope for next year. Hope everything works out for you!! I may go thru something similar when they try to get my sleeve approved. Instead of one WLS per lifetime, my insurance has $4000 lifetime maximum on bariatric procedures. I had my band removed on 5/22, I'm hoping bc of emergency it is not put towards that $4000. Good Luck!

[Teachingmom 3]

Thanks to all of you who have replied! I am on a constant roller coaster. I get my hopes up then get bad news from insurance then y'all give me hope again! I so wish we didn't have to fight for something that will improve our health! Maybe we are paving the way for bariatrics care down the road! If I had the cash to do it I would not even hesitate. So insurance is my only option. I have 4 kids, with 2 in college & another one going next year. So taking a loan out for my surgery is not an option right now. I am just hoping an appeal or the peer to peer will be my saving grace!