I have been denied by BCBS.....

[piercedqt78 658]

I am waiting for the doctors office to call me back with the reason for the denial. I called to check the status and the insurance compny said a letter was faxed to the office and one was mailed to me today and could take up to 2 weeks to arrive. I called the office and the co-ordinator is going to get my fax and call me back.... This stinks...~Mandy

[Mita 2]

Mandy maybe the reason is something you and your doc can work around. Crossing my fingers for you.. Remember you can always appeal

[Iluvharleys 15]

Mandy maybe the reason is something you and your doc can work around. Crossing my fingers for you.. Remember you can always appeal

I agree, it's best to wait and see exactly what they say and if the doctor can fix the problem. Good Luck!

[piercedqt78 658]

They have the band listed as experimental... the surgical co-ordinator says that it is pointless to appeal as they will deny me again. I am going to try to get it financed. Anyone have a good source? ~Mandy

[Alexandra 55]

Mandy, it is NOT pointless to appeal!! This is exactly why I was denied and here you are two years later hearing the same B.S. that I did. The band has been approved by the FDA for almost four years--it is NOT experimental and all you need is an outside opinion.

Does your state offer third-party appeal rights? New Jersey does and I know it's not alone in doing so. Call your state department of insurance or health (whichever has jurisdiction over HMO decision) and ask what your recourse is if you don't agree with your carrier's decision. Maybe there's nothing you can do. But maybe there is, and if you win you'll not only save yourself thousands of dollars but you just might make it easier for the next person. Appeal!!!

[the best me 6]

Also, check out this thread. It's Colorado, but it might be a ray of hope? You could site BC/BS Colorado in your appeal? Here's the thread...

http://www.lapbandtalk.com/showthread.php?p=75508#post75508

Good luck!!

[piercedqt78 658]

I am going to appeal. I spoke with the surgical co-ordinator and she offered to help any way she can, she is the best!!! I am going to call the Illinois Insurance review board and see what is available to me. If the insurance is from philly and I am in Chicago what states review board should I call? I am also going to call the Union Pacific (hubby's employer) and see what they can do for me. I think there are 2 options with them, they can call bcbs and get it approved or they can let me change insurance carriers, they also have United Health Care. I was not aware that the policy would be so different. My mom has UHC and they told her on the phone today that with the diag and proceedure code that I had it would be covered if medically nessary. (my step dad and husband are in the same union therefore we have the same insurance) Say a prayer for me tonight, I need it~Mandy

[Mita 2]

Keep us posted you can get alot of help from others that have been told no only to get a yes after fighting.. Don't give in or up:)

[I'llsucceed 1]

YOU GO GIRL- Its always worth the appeal! Alex gave great advice as usual. WHile your doing the appeal try & line up the finances at the same time just in case. That way either way w/in afew months or less you will be setting your date. Best of luck to you!!

I believe you will definetly be accepted after your appeal-especially if that is the only reason they gave you. Your very close to Michgan & there is a very well priced surgeon here for self-pay people. If you need info please just ask :0)

[Alexandra 55]

Mandy, it sounds like you have a lot of options. Don't give up!! What you do will quite possibly help a lot of people down the road.

As far as which state has jurisdiction, check your contract. Some out-of-state policies abide by the state where the employer is sited, but in some cases carriers write contracts separately for employees in other states. There's no hard-and-fast rule about this.

Good luck and please keep us posted on your appeal!

[piercedqt78 658]

Does anyone think that contacting Inamed will do anything for me? Will they send BCBS the information to support the fda approval for the band showing it is safer and just as effective as GBP? The reasons for the denial are as follows:

"A proceedure or treatment is considered experimental/investigative if:

1) the intervention does not have FDA approval to be marketed for the specific relevant indication (or)

2) available scientific evidence does not permit conclusions concerning the effect of the proceedure or treatment on health outcomes (or)

3) the proceedure or treatment is not proven to be as safe or effective in achieving an outcome equal to or exceeding the outcome of an alternative therapy (or)

4) the proceedure does not improve health outcome (or)

5) the proceedure or treatment is not proven to be applicable outside the research setting"

I don't feel that any of these describe the band at all...that is why I was thinking that maybe Inamed would be able to help out. Will they defend their product? ~Mandy

[Mita 2]

I cannot believe that BC/BS is stating that when in other states the cover it.

For instance BCBS of Nebraska covered it before 2005 I did mine in 2004 and they paid. I know every state and employer Policy is different. I would call and talk with them and point that out and see what they say. I'ts worth a shot

[piercedqt78 658]

Are insurance companies always this wishy washy? I called to get DETAILED reasons of why I was denied and they are now saying that it is not experimental and that they do infact cover it. I just have to appeal and have the doctor call and do a peer to peer phone conference. The lady that I talked too said that she has seen hundreds of these approved in appeal. She also said that it was a poorly worded form letter that was sent to me and I had a really good chance of being approved if I appealed with help from the doctor and I also called Inamed and they sent me a bunch of reports that I can include in my appeal. They will help with appeals if anyone needs them too, they do a whole appeal package. I am going to call the doctors office tomorrow and see if they can do a peer to peer for me. Wish me luck~Mandy

[Alexandra 55]

Mandy, insurance companies are indeed often wishy-washy. The form letter you got sounds like something that's outdated. Good luck with your appeal and I just KNOW you're going to be successful!!

[PomMom 0]

Mandy,

I was recently approved by EmpireBlue PPO [a BC/BS of TX company]. When I was was waiting for approvals I noticed that people on other support Yahoo groups that I joined indicated that Inamed has also been helpful in rectifying the 'experimental' classification. I'll see if I can find the Inamed person's name that can get you information to overrule the experimental excuse.

Good Luck and do not give up!