Any suggestions???

[**LaP HaPPy** 0]

Hey everyone! For weeks I have visited the site gathering info and gaining insite into life with the lap band. It has been so helpful in my decision to have a lap band placed. It seems only natural to turn to you for help with my latest brick wall.

I know we all have had issues with our insurance companies, but my United Health Care company has truely deadened my spirit. On 4 different occasions I called to see if Lap Band surgery was covered, and 4 different people told me it was, following a medical review. I completed all of the necessary evaluations (psych, nutrition, diet history, etc) and sent the info off for review.

I called on 1/13 and was informed that it was declined for lack of coverage. I was so stunned, I just hung up the phone.

I called back on 1/15 to find out how this could have happend and was told that it was an error, and they would send it back for an urgent review.

I called back again on 1/16 and was told the review was denied again and that I do NOT have coverage. I told her about the 5 other times someone have confirmed coverage,and she said that they were not following the proper procedure in looking up obesity surgery. She told me that it is an exclusion in my policy. She gave me the address for an appeal, but told me that it was not likely they would change their minds.

Needless to say, I am completely devistated. I am not only out the $500 I have spent so far, but more importantly, struggling to think of ways to get the 15K for the surgery.

I am seeking your advice! Anyone have something like this happen to them? Was it worth the time and energy to fight the insurance company? I was told by my doctor that fighting an "exclusion" was more with your employer, and I can only imagine what that would be like. (my hubby works for state government)

I am just looking for any info you guys might have. Thanks so much for your support!

Niki

[conniesueb 1]

Hey Niki--I know how frustrated you must feel. I have United HealthCare too(at least I did last year when I had the surgery), so I had to go thru the same thing. When I first called, I was told that coverage for lap band surgery is determined on a case by case basis, but that if it was covered, it would be at 90%. So, I got all my paperwork together(with lots of help from the doctor), and sent it in for approval. My doc does not bill insurance directly anymore after getting burned too many times, so I had to pay up front. I did get a letter from insurance saying the procedure would be covered, though. So, now I am waiting to be reimbursed, and have called twice to see what the hold up is, and all they tell me is that it is still in review. Frustrating! I borrowed money from my mom for surgery, and if they end up not paying me back, I am going to really be pissed! The other thing I am worried about is that they will only pay for the doctor, and not the anesthesia and facility charges(which was more than the doctor's charges) I work in a dental office and have to deal with insurance companies every day, and it seem like if there is a way to get out of paying for something they should pay for, they will somehow find a way around it, and there is nothing you can do about it. It sucks! But, I would definately file an appeal--the worst that could happen is that they will say no. Hang in there, and good luck!

[Wheetsin 714]

I have UHC and they covered me no questions asked. And that's with no comorbidities. And I know it's something the generally cover, so I'm assuming the exclusion is on behalf of your employer?

If you don't already have it, ask your plan administrator to send you a copy of your "SPD" (summary plan description). This will detail your benefits and rights under your plan. If you have it, share with us what it says related to "surgical treatment for morbid obesity", or whatever verbiage it includes to cover "gastric banding" (don't try to find "lap-band", just look for "gastric banding" or "adjustable gastric banding").

The good news is that if your plan covers it, and your employer does not exclude it, you should be able to get coverage provided you meet whatever the criteria are. Bad news is that if it's an employer exclusion, there's not a whole lot to be done, generally.

[**LaP HaPPy** 0]

Thanks for the info, guys! I am having my hubby get a copy of the SPD on Monday. I will let you know what I find out! Thanks again!

niki

[juliegeraci 7]

Sorry you are going through this. I would push them again. I have United Healthcare and I was covered. Good luck.

[**LaP HaPPy** 0]

Hey guys!

Just wanted to update you on what I have found out. My husband got a copy of his exact coverages, and the band (GBP too) are infact an exclusion. I am not sure why the five insurance people I talked to on 5 different dates told me it was a covered benefit. I plan on using this in my appeal. The hardest part of this is knowing that I chose to use my husbands insurance bc I thought it had better band coverage. What a joke!

I have to talk to my DH and decide where to go from here. I would really love to try to get it financed and have it done soon, but I think 15K is a lot to ask of my family. (I have two small children and I only work part-time) I might end up having to wait til next Dec for open enrollment and go with my insurane company. I just can't believe this is happening!

My question for you guys is how many of you had a BMI of less than 40 when insurance aproved surgery. What were your co-morbitities? How severe where they? Even if I have to wait a year for surgery, I can't live like this. I am just afraid to lose weight and not be covered by my insurance next year. My BMI right now is 41-42, but I am not on any meds for my Blood pressure or asthma.

Thanks again for the help guys!

niki

[JulieNYC 4]

Niki,

Hire a lawyer. Also, please keep in mind that if you appeal on your own, you usually only have 2 appeals (check your policy on this) before the issue is foreclosed forever. Don't not hire a lawyer, appeal on your own, then find out a lawyer could have helped you. Even when there is an exclusion, lawyers can sometimes get around that because it can be determined to be medically necessary for people with 40+ BMI.

Check out the following website. I've not used it myself, but have heard only good things about Walter Lindstrom. He also addresses your exact question in the FAQ:

http://www.obesitylaw.com/

[chattanoogabrat 0]

I had UHC and did have other health problems but after all the paperwork was submitted to the insurance company I approved within abt two weeks and its up to your employer whats covered. I also along with all the surgeon paperwork I requested to have my 5 page medical letter of necessity I wrote to the insurace company why they should pay for it.

[**LaP HaPPy** 0]

Thanks Julie! My Hubby came home tonight and told me about the website, too. Maybe that is a good sign!

niki