Frustrated over Insurance Denial

[rccbrandon 0]

I am hoping that someone here might have had a similar experience as me and can give me some pointers.

I had my lap band surgery in April, 2008. I did fairly well in the beginning and lost a majority of my weight in the first 2-3 years. Since then, I've yoyo'd within a few pounds. I went regularly for adjustments but got close to the max for my band and started having problems eating. There wasn't really a meal where some part of it didn't come back up (my lap band folks know what I mean). I got sick (Bronchitis) back in December and went to see my PCP and talked about my unhappiness with my overall results. She referred me to a surgeon at a different hospital who was doing a lot of revisions. I went to see him in early January and told him about all the problems I was having. He sent me for a swallow study and determined that my band was inflated too much. At my next appointment, he removed all the fill and now I have almost 0 restriction.

In the midst of all this, the office submitted to my surgeon to see if my insurance would cover my revision. Like I mentioned earlier, I didn't lose all that much weight. My surgeon is from Europe, where they have been doing lap band longer than in the US, and there is has been found not to have good long term results. My current surgeon isn't even doing the lap band anymore for this reason.

Long story short, my initial pre-certification was denied and my initial appeal was denied. I didn't go through all the pre-op appointments I (I did cardiology and psychiatrist) because I didn't want to do them all if I was going to be denied, but now am wondering if there wasn't enough ammo for insurance to pay for revision. I had Keystone when I had the initial surgery and am back to Independence Blue Cross (PPO) (the same insurance company) and that is probably the reason I'm being denied. My BMI is still over 40, and am getting even more discouraged due to having gained back a nice amount of weight.

I'm about to file the 2nd level appeal. Has anyone gone through this and had decision reversed? What did you say during 2nd appeal. I'm looking for guidance from anyone who may have gone through the same thing.

Thanks!!!!

[SusanB55 89]

The insurance should have said why it was denied!! Did anyone tell you why? After all I've read and heard, including numerous phone calls to my BCBS, there is protocol you need to complete prior to submission. You need Nutrition appts with a dietician, dr supervised weight loss appts, and psyche all within a certain amount of time. It varies with different insurance. You have the BMI covered, but sounds like that's all. You have to jump through all the hoops if you want to get approved. I would call insurance myself and ask how you can fix this.

[dede0314 356]

I don't have blue cross but I did have to go through appeals with my insurance company. I actually had to go through an external review appeal and the denial got reversed. All I can say is don't give up and get all the information you can about their appeal process and why they are denying you.

[rccbrandon 0]

I was denied because BCBS said the revision wasn't medically necessary. I've had the Psych, and the Cardiology, and I'm going for the sleep medicine MD tomorrow. BCBS also stated that they only cover 1 bariatric procedure per lifetime, though my MD office said they've seen that reversed. I'm getting even more frustrated because since I had to have all the fill removed from my band, I've gained like 30 pounds back. The best part is, that my eating habits are better now (not eating as much junk) than when the band was filled and I've gained so much weight back.

[dede0314 356]

I had LINDSTROM OBESITY ADVOCACY-WWW.WLSAPPEALS.COM help me with my appeal. Maybe you can give them a call to see if they can provide any information. They'll let you know if they can help or not if anything they might be able to at least give you a little knowledge.

[SusanB55 89]

I was denied because BCBS said the revision wasn't medically necessary. I've had the Psych, and the Cardiology, and I'm going for the sleep medicine MD tomorrow. BCBS also stated that they only cover 1 bariatric procedure per lifetime, though my MD office said they've seen that reversed. I'm getting even more frustrated because since I had to have all the fill removed from my band, I've gained like 30 pounds back. The best part is, that my eating habits are better now (not eating as much junk) than when the band was filled and I've gained so much weight back.

This is what I am worried about. BCBS may not think my revision is medically necessary. So the doc is going to have to make the case that I've been vomiting for years and have already had one slipped band (not this current one tho as I had an upper GI-all looks ok) and a hiatal hernia. The other band was replaced under a previous insurance. It is REALLY going to suck when/if my husband has his sleeve and I'm still stuck with the band that is nothing but trouble.

[Mburk72 13]

I was denied because BCBS said the revision wasn't medically necessary. I've had the Psych, and the Cardiology, and I'm going for the sleep medicine MD tomorrow. BCBS also stated that they only cover 1 bariatric procedure per lifetime, though my MD office said they've seen that reversed. I'm getting even more frustrated because since I had to have all the fill removed from my band, I've gained like 30 pounds back. The best part is, that my eating habits are better now (not eating as much junk) than when the band was filled and I've gained so much weight back.

This is what I am worried about. BCBS may not think my revision is medically necessary. So the doc is going to have to make the case that I've been vomiting for years and have already had one slipped band (not this current one tho as I had an upper GI-all looks ok) and a hiatal hernia. The other band was replaced under a previous insurance. It is REALLY going to suck when/if my husband has his sleeve and I'm still stuck with the band that is nothing but trouble.

What state are u in, bcbs is different in each state. Your story worries me because I have Bcbstx and I'm currently waiting on insurance approval to have my band removed, and revise to the sleeve. Bcbstx does pay for first surgery, 2nd and revisions, they list requirements for each. I meet their requirements for 2nd surgery which would be removal, and I also meet revision if I have slip, dilation or erosion. My surgeon says I have some slip, just don't know if it's enough for them, so I'm still waiting to see what they say, its been 1 week since documents where submitted

Sent from my XT1254 using the BariatricPal App

[SusanB55 89]

I was denied because BCBS said the revision wasn't medically necessary. I've had the Psych, and the Cardiology, and I'm going for the sleep medicine MD tomorrow. BCBS also stated that they only cover 1 bariatric procedure per lifetime, though my MD office said they've seen that reversed. I'm getting even more frustrated because since I had to have all the fill removed from my band, I've gained like 30 pounds back. The best part is, that my eating habits are better now (not eating as much junk) than when the band was filled and I've gained so much weight back.

This is what I am worried about. BCBS may not think my revision is medically necessary. So the doc is going to have to make the case that I've been vomiting for years and have already had one slipped band (not this current one tho as I had an upper GI-all looks ok) and a hiatal hernia. The other band was replaced under a previous insurance. It is REALLY going to suck when/if my husband has his sleeve and I'm still stuck with the band that is nothing but trouble.

What state are u in, bcbs is different in each state. Your story worries me because I have Bcbstx and I'm currently waiting on insurance approval to have my band removed, and revise to the sleeve. Bcbstx does pay for first surgery, 2nd and revisions, they list requirements for each. I meet their requirements for 2nd surgery which would be removal, and I also meet revision if I have slip, dilation or erosion. My surgeon says I have some slip, just don't know if it's enough for them, so I'm still waiting to see what they say, its been 1 week since documents where submitted

Sent from my XT1254 using the BariatricPal App

I am in Arizona, BCBS Fed. I'm sooooo scared that we will deny me!