Medicare Lapband Revision Denials Low BMI

[SKF 16]

I am reaching out to anyone who can share help in getting Gastric Sleeve approved by Humana Medicare after an emergency Lap Band Removal with a low BMI 30.

Are there Any Advocates that can help with a denial and now trying to Appeal?

This is just not fair. I am sure there are a lot of Lapband removals Out there. Medicare guidelines are not up to the times of all these problems that are going on with failed Lapband and medical issues causing patients.

Thanks for any feedback.

BTW they told e to reapply when I reached 35... I have 3 of the comorbids and my band was successful too for me for 5 years.

Edited January 4, 2018 by SKF
Added comments

[Jengo825 37]

If this was an emergency revision, the denial could be due to incorrect billing codes. I had the same problem with my revision so I contacted my surgeon’s office to check the coding. When they recoded as an emergency (which it was) insurance paid for it. I am on Medicare so they don’t pre- approve, so when I got the bill, I was shocked too! I also found out Medicare doesn’t pay for more than one surgery at a time and mine involved 1)LB removal 2) Bypass 3) and hernia repair. The bariatric center recoded and gave reasons why it had to be done at once. So anyway...have your Bariatric center help you. Best of luck getting your sleeve....and with your approval.

BTW, my secondary is BCBS. However, any secondary should pay the remainder if it is approved my Medicare.

[SKF 16]

Hi! Thanks for sharing. They paid the Lapband removal. 3 months ago. They denied the sleeve... I self paid had surgery 12/28 and going to try and appeal the denial. So far so good with my sleeve surgery. I was gaining weight the past three months 25 pounds and sleep apnea .. other past issues come back. I didn’t want to gain more .. and let my health go down. Down 11 pounds. :).

[shedo82773 1,236]

Like was said above, have your Surgeon's office do the dealing with your insurance. They should know how to code it in a way to get it approved. The one who does their approval letter should know exactly what to do. I am also on MEDICARE and it was kind of scary when they have you sign a contract that you will be responsible if MEDICARE doesn't pay. I do know that Medicare pays the Surgeon a blanket amount for the beginning of your surgery until you are well. Thankfully everything worked out for me.