Insurance Denial of Adjustments/Fill AFTER having surgery

[Looking Up 0]

Has anyone had this problem and been successful in getting the insurance company to overturn their decision? I had my lap-band surgery pre-approved and had the procedure done on March 3rd of this year. I will be ready for my first fill on April 22 and have an appointment all set. When my doctor's office called the insurance company (Unicare), their pre-certification people said adjustments/fills are not covered!!! Say what?????

I don't get it.... you can approve the surgery, but then leave me hanging there? I sort of feel like what if I were a patient having breast reconstruction following a mastectomy.... have you seen some of those surgeries? Sometimes they put in delated implants and have to fill them up once they are in place? So if I were one of those women, would they say we'll cover the surgery to put them in, but not to have them filled and be willing to leave me hanging with empty bags in my breasts?

Back to my original question... anybody have this problem with their insurance company and if so, were you able to get it overturned and how did you do that?

[Wheetsin 714]

I did not have that problem, but as crazy as it sounds, your story is far from the first time I've heard it.

I've never heard of someone getting it overturned. There's really nothing to overturn. Either they cover it, or they don't.

I *think* (it has been at least 6 - 8 months since I've seen something come up on the topic) most people considered themselves lucky to have the bulk of the costs covered, and decided the fills were a reasonable cost to assume (not saying this is what you should do, just the outcome I remember most clearly).

Also, check with your surgeon. Mine, and many I've heard of, include fills for a set amount of time... usually a year (if they do it). So OOP costs might not begin until 12 mos post-op. Mine were free for a year, and after that my co-pay kicked in.

ETA: try searching for related keywords. I *know* this has come up before, and should still be here somehwere.

[Cristay30 0]

I've heard this. My surgeon told me that UHC will cover the surgery but not the fills after. I called UHC myself and they said ya your employers policy does cover the surgery itself but not any fills after that. I asked why and the UHC agent said I don't know but to me it makes no sense either. He stated that the office visits will be covered but not the fill itself, for that you will have to pay out of pocket. So my surgeon is charging $100 per fill and from what I heard it could take 4-8 fills to hit the "sweet spot". So I've started saving money for fills.

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Thanks for your responses. I wouldn't be balking so much if my doctor is charging me $100, $200 or even $300 for a fill, but they are going to charge me a whopping $800!!!

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In case anyone is reading this thread, I just wanted to provide an update on what happened with my insurance company. I submitted a grievance form noting all the reasons why the adjustment/fill is necessary. And then my doctor's office submitted in writing a request for pre-certification. They initially denied the pre-certification on the phone. I say don't accept a phone denial, get it in writing. After about 3 weeks we got notice that they were going to approve the adjustment/fill. Hallelujah!!! :coolgleamA:

I think the problem with my insurance was that they just started to cover the lap-band as of January 2008 and they either were not familiar with the fact that there are adjustments/fills that go with it. Either that or they just didn't have it in their system yet or hadn't trained/educated their reps on it.