What you should know if you get DENIED....

[josiek1988 70]

@@liposuction68, i am actually not scheduled yet. I am about midway through the process of band to Sleeve revision. August was a guesstimate. I had been having issues but was without insurance for a minute because we moved from Indiana to Ohio. Once I got here I found a surgeon, had an upper gi and EGD. Now I am just working the program with the Nutritionist. Hoping for late July or early August.

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[liposuction68 178]

Oh OK. Good luck on ur journey

[josiek1988 70]

Thank you

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[Sunyinflorida 8]

As mentioned in my profile, I currently have a lapband in place. I am having complications so I am looking at my options, along with familiarizing myself to my ins co requirements. However, I also know my surgeon's staff have the approval process down pat. They had my lapband approved in one day. Even the legal advocates like Lindstrom will say one of the top reasons procedures are denied is not meeting criteria or not providing sufficient documentation.

The insurance industry is so heavily regulated by both the state and federal governments, that neither would allow the nefarious process of compensation based on denials. I, too, have been in the insurance industry for almost 30 years. I have assisted folks in understanding their Bariatric benefits and what materials they need. I have seen the lack of the dr office not wanting to provide that info and dealing with frustrated members. I'm fat,too, so, my empathy is with the member. I helped them finally get their surgery covered and didn't get fired for getting the surgery covered and costing money! Instead. I got a pat on the back for helping our member and making them happy.

[liposuction68 178]

Hi sunyinflorida, i liked your post and then i thought about it how to answer without offended you or anyone else that works in insurance... that is exactly my point you were or are a bariatric patient "i am fat" so you "i had empathy" with those claims that came through.. We all should have the privilege tp have someone like you to review our case especially when we have everything that we are suppose to submitted. like i said we all pay for our insurance and its not a pretty penny especially if its ppo and i do understand knowing and reading your policy and knowing whats in it. i can tell you for sure there are many people who has not registered onto their insurance website. i did and i actually spoke to a doctors office of mine that submitted a claim for a visit that i had cancelled instead of calling my insurance first i called the doc and asked if i was charged even though i cancelled and they said no and i said well someone did and that i didn't want to get anyone in trouble but they better fix it asap because it shows that they put the claim in. i guess they were shocked office manager called me and said they were going to reverse or whatever cause i did not have that appointment. So , i say this to say we need more people on our side WLS . i mean really can a dentist reviewer tell me if i need this or not if it is covered in my policy .. can a skinny person if they are not mad at the world for something else approve even if its in the policy. i do feel like someone above said we have to deal with mood swings skinny people and just woke up on the wrong side of the bed even if our insurance covers it. IM JUST SAYING..

[2goldengirl 2,076]

i mean really can a dentist reviewer tell me if i need this or not if it is covered in my policy .. can a skinny person if they are not mad at the world for something else approve even if its in the policy. i do feel like someone above said we have to deal with mood swings skinny people and just woke up on the wrong side of the bed even if our insurance covers it. IM JUST SAYING..

It doesn't work that way. Whether something is approved or not is about what the criteria are, and whether the information submitted shows that the member meets criteria. Period. It has nothing to do with what mood anyone is in or how skinny they are or are not. I'm one of nearly 20 individuals at my company who do this, of all shapes, sizes, moods, what have you. We're professionals. It's our job to advocate for the member, period. If something can't be covered, it's our job to help them to understand why not. This is true whether the issue is bariatric surgery, knee replacement, consultation with a specialist, or a medical equipment item.

[liposuction68 178]

ok

[Alex Brecher 10,512]

@@josiek1988,

Thank you, thank you, thank you! Most of us have no idea how insurance companies operate. All we know is that we get letters of denial, and get placed on hold when we try to call. Thank you for this piece of advice. I am sure it will literally help hundreds of grateful patients.

Some of the others also posted good advice – ask your surgeon’s office to contact them for you, both to get better results and to avoid confusion.

[liposuction68 178]

That;s if you find or have a doctors office that will go beyond for you. sometimes they just have to many patients to get through the process than to spend all their time on one... Do you think the insured should contact their own insurance company also and stress them out like they do us. im denied 2x i just put a call to my lawyer to get involved appeal letter. i was denied first time because of missing information and now because bmi is not high enough .... from what i have heard a bmi is shouldnt be considered in A BAND TO SLEEVE REVISION. correct me if i heard wrong.

has anyone been approved after being denied twice for a Failed band to sleeve Revison. please comment.

thanks

[km30381 2]

I had my lap band placed in 2006. I lost over 100 lbs. Loved it. I had to have it removed in Oct. 2014 due to a slip. I have been fighting my insurance company since. Many appeals and denials. As my last resort I hired Lindstrom Weight Loss Advocacy. They did some research and I was floored to find out some things the insurance company did. My review and denial was done by a "pediatrician" among other things. They just do not want to pay for it. If I had saved all my insurance premiums I would be able to pay cash for my sleeve. I am waiting now for what will be my final answer. Should know by mid April. I think the appeals come through and just automaticly are denied. I have gained back about 70 of the 100 that I lost. Fingers crossed. Good luck everyone.

[liposuction68 178]

WOW km30381, i had to look back to see who was writing this i thought it was my story. dang! i already called lindstrom they sent me the proposal but is confident if i dont get this Peer to peer review than they can help. yes i was denied. 2 X

and monday is my peer to peer im prepared to go to Mexico too yup cause i cannot wait any longer. i will continue to fight when i get back this time for the payment reimbursement.yup i will let everyone know by wednesday hopefully.

[josiek1988 70]

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[2goldengirl 2,076]

@@josiek1988, sorry, but that doesn't work. The process of making medical necessity decisions is compliant under HIPAA. Committees don't make these decisions. Individuals do. For any health plan that is accredited by either NCQA or URAC, a decision to deny based on medical necessity has to be made by an MD with an unrestricted license to practice in the state where the member lives.

Edited April 4, 2016 by 2goldengirl

[SusanB55 89]

I had my lap band placed in 2006. I lost over 100 lbs. Loved it. I had to have it removed in Oct. 2014 due to a slip. I have been fighting my insurance company since. Many appeals and denials. As my last resort I hired Lindstrom Weight Loss Advocacy. They did some research and I was floored to find out some things the insurance company did. My review and denial was done by a "pediatrician" among other things. They just do not want to pay for it. If I had saved all my insurance premiums I would be able to pay cash for my sleeve. I am waiting now for what will be my final answer. Should know by mid April. I think the appeals come through and just automaticly are denied. I have gained back about 70 of the 100 that I lost. Fingers crossed. Good luck everyone.

What insurance do you have? Does Lindstrom charge a lot to help?