My insurance denied coverage...

disney38 · March 20, 2007

so I have been researching lots on this website and other places. I found a doctor whose weight loss coordinator can't figure out why I got denied, and thinks she can get it approved.

I have a BMI of 38 and have sleep apnea. They denied me because the sleep apnea is controlled by CPAP. Long story, but I did my sleep study last July, got the CPAP, and had a follow-up appointment with the sleep doctor. Truly, I did sleep BETTER, but by no means do I sleep all night without waking up a few times. If I knew then what I know now......

At any rate, I do not think I am handling the CPAP very well. I take the thing off in my sleep (or my awake) and don't even realize I had done it. I have a doctor appointment this week where I hope they will document in my medical records that I am not sleeping well even with the CPAP.

I have also committed myself to paying for lap band surgery. Now I am in a quandry. I really would be much happier having my insurance pay for this, but not sure I can handle another denial.

Anyone who has been denied, have you ever gotten it turned around? My appeal was denied too, but at that time, I think the CPAP was rather new and I didn't have much time with it.

I have decided if I am self pay I will go to Colorado to have this done with Dr. Kirshenbaum. For those that did this, did you have air travel? Were you able to travel right after surgery? Would you recommend this doctor/clinic for this? It seems that what I have read has been very good.

Also, my biggest fear of all is that I will fail. My DH has seen me go through much money on many different diets. I KNOW that the lap band itself will not make me lose weight, but I am hopeful that it will help me. Any comments greatly appreciated.

Thank You.

faithmd · March 20, 2007

Disney38, I'm sorry about your denial. If I were you, I'd call my insurance company have them explain it to me, and then I'd ask what I need to do to be approved and have them mail it to me so I have it in writing. I would not reapply without knowing EXACTLY what it was that got me denied, because the more times you are denied, the more you risk never getting that approval. Some companies have a "three strike" rule, if they deny you three times, you have no more chances for approval. One suggestion is to check out www.obesitylaw.com, the site is for a lawyer who is fairly successful in fighting denials. He costs a little bit but it's far less than paying yourself for the surgery. Fees are on the site.

Here's a link to the thread about Dr K.:

http://www.lapbandtalk.com/considering-dr-kirshenbaum-t26213.html?t=26213

Many people travel long distances to be banded, it is possible to do.

sunnysea · March 20, 2007

Disney 38, I am from N.E. Wisconsin and am a self-pay, our ins. has it excluded even if medically nessesary:cry I also have sleep apnea but hate my cpap machine so I haven't been using it and I suffer from fatigue because of S.A. I found out about Dr. Kirshenbaum from this website and I am very happy with the whole outcome. In Wi. I was going to pay $17,700 but I was unable to come up with the whole amount of $$$$. I called out to CO. and the rest is history. Dr.K. and his staff are wonderful, he takes time to answer any questions and concerns, I was also very impressed with the care I recieved from HealthSouth the surgical center. I have not read one single negative post about him, his 2 staff people have been with him for 25 years, also my surgery was only a few weeks ago and my incisions look great, not like some i've seen. Anyhow good luck in what ever your choice is, you can also find out more at (lapbandrockies.com) Take care, Sunnysea