I think it's over !

Paparazzi · May 14, 2005

I think I've gone as far as I can go with insurance. I lost the 2nd appeal and my insurance company said that my employer didn't allow external reviews for "experimental procedures" (Anthem BCBS).

I paid a lawyer $900 to handle the appeals but it's been 2 months since I've had a real conversation with him and he won't return my calls. I even tried talking to his secretary and was told that she was out of the office... she didn't even call me back. The only way that I know that I lost the 2nd appeal was that the insurance company did return my call... after three weeks. I'm beginning to feel like a non-person.

Anyone know of a inexpensive band doctor around Ohio.

cathy

farmgirl · May 14, 2005

I will probably end up self pay. I spoke to the Wish Center, in Chicago yesterday and self pay is 11,000. Fills are extra, vary from 105-160 depending if need barium swallow. Chicago isn't too far depending on where you are in Ohio.

Shelley

birdee · May 14, 2005

I am sorry you are having a tough time! You would think with all the proven results, the lapband would be covered by all insurance companies! :tired

I am not in the OH area. I am sure someone will be able to offer you more assistance.

Paparazzi · May 14, 2005

Funny thing is that I have a Wish Center just five minutes away from me. I don't know what their rates are. I've been afraid to go there because they are associated with the hospital that I worked at for 30 years. There would be no privacy. I know everyone at that place. Wonder if I could have my surgery in Chicago and fills here in Ohio. That might work. Thanks

Cathy

Alexandra · May 14, 2005

Cathy, I was denied by my carrier for the same reason back in 2002. Now the band has been FDA approved for almost 4 years, it's absurd that they can claim "experimental."

Call your state's department of insurance or health (whichever has jurisdiction over health insurers) and ask if you have recourse for third-party review of your insurer's decision. This is a right in my state and I won--my carrier's denial was overturned and they had to pay for my surgery.

Don't give up, it can be done! Good luck!!

aileena · May 14, 2005

Maybe it would be benificial to get ins with a co that will pay...pay for a few months, then apply for the band again

Paparazzi · May 15, 2005

I did email a complaint to Ohio's insurance board. They said that they would get back to me in a couple weeks, but it sounded like all they were going to do was forward my complaint to my insuraqnce company. Like that would so any good.

My husband could have changed insurance last November. There were two other options. One had a direct exclusion and the other was so expensive that it wasn't worth taking a chance to find out if they had an exclusion or not. I think that I'll look into self pay.

Aimze · May 15, 2005

I am still fighting to get my band . I even called up my state attorney general they can be pretty helpful depending on the ins. plan you have. And I would keep calling the attorney you hired and get some answers. Thats really rotten that she is so un helpful. you paid for the service.

Good luck.

Amy

Jammin & Losin · May 15, 2005

Cathy~ I'm sorry you are going through such a hard time but hang in there and even if it comes down to self pay. You will get that band and your health back!!!

Lu Ann · June 6, 2005

Cathy,

I am in Texas, but have Anthem BC/BS, PPO. I called them about this procedure a couple of weeks ago. "Jenny" told me that it is covered if you send the following; She called it criteria for pre-determination.

1. Recent physical with office notes

2. Therapy progress (previous attempts at losing weight, programs you have tried, diets tried, and meds taken for weight loss.

3. Letter of medical necessity

4. Nutritional evaluation

5. Psychological evaluation

I got the names of the nutritionalist and psycholigist from the doctor's office where my appointment is (Dr. Spivak) in Houston.

The way I understand it, if all these things are faxed to them, you will be approved.

Praying for you!

I see you sent your letters in March, could it have changed since then?

DeLarla · June 6, 2005

And call the State Bar Association and tell them you paid $900.00 to a lawyer who did nothing and won't return your calls. Don't hesitate.

GeezerSue · June 6, 2005

...
My husband could have changed insurance last November. There were two other options. One had a direct exclusion and the other was so expensive that it wasn't worth taking a chance to find out if they had an exclusion or not. I think that I'll look into self pay.

If you're talking about an open enrollment period at his place of employment, you don't need to take a chance. Call the insurance company--or check their website--to determine their policy for covering bariatric surgery. (And don't let them get away with saying it has to be "medically necessary." When they told me that, I said, "So, if any doctor says I need this, you're going to pay for it, right?" THEN, they found the criteria.) If it looks like you meet that criteria, change insurance in November, but change back the following year. Unless the insurance is $1000/month out of pocket, you'll still save money.

And even if THAT doesn't work, see if his employer offers a Section 125 account, which will let you pay out of pocket with tax free money.