Has anyone been reimbursed after self-pay?

[ML in VA 0]

I was recently denied by Cigna for lap band surgery due to "lack of medically necessity." My secondary insurance, Tricare Prime, has advised that they will deny me as well for the same reason. I've decided to self-pay and plan on submitting the bill to both carriers after surgery to see if I receive any reimbursement at all. Has anyone tried this and been successful?

thanks,

ML

cw 280

gw 60

[Lanakila 1]

ML, I haven't had any difficulties like this but I've read in many places on this board that whenever you are denied you should appeal. These appeals have been VERY successful. Good wishes in your journey!

[smidgen21 0]

Do you have a copy of their bariatric surgery guidelines? After my denial, my surgeon wrote a letter outlining how I fit their guidelines. My appeal was approved!

[ML in VA 0]

I spoke with my surgeon about appealing. He doesnt think it will get approved, since his experience with Cigna is that they're the toughest. Since I have Cigna and Tricare, Im thinking that someone should reimburse if I self-pay.

The primary reason for the denial was lack of medical necessity, but they also list that my BMI has not been high enough for 24 consecutive months. They also cited that since I did not have 6-months of doctor supervised vists, even though I was only missing one month.

I'm so ready to make this change - both of my parents suffer from diabetes, hgh blood pressure and cholesterol. My mom just had the surgery and within 2 months is off all meds! I know that I need to do this now and I don't want to be at the mercy of an insurance company to make the determination on my life and health. I have the ability to pay (thank God) but I want the insurance company to be on the hook for something.

Thanks for your replies and suggestions!

ML

[JamieNP 20]

ML, how much over weight are you according to the metlife wt scale? What is your bmi?

[ML in VA 0]

I am 5'9 and weigh 280 (approx. 120 pounds over high end of my ideal weight range) My BMI is 41.5.

[JamieNP 20]

I would appeal!!! You are 200% overweight. Did you get a sleep study done? Do you have ANY comorbidities???? Appeal!!

[ML in VA 0]

No comorbidities and Cigna didn't require a sleep study so I didn't have one done. My PCM even wrote in her letter to my surgeon that although I am considered obese, I am considered "healthy." I suspect that word may have been a red alert for the insurance approver.

[droppindown 0]

I am in the same boat as you. I was denied for lack of diet history although I had years of medical records. I did not want to wait, I self-paid and am now going to appeal and try for some type of reimbursement. By going self-pay, I will have saved them $8k over the insurance price. I am glad I went this route, I have lost 27lbs since May 29th and am feeling great. Maybe if I get a lawyer involved I can at least get partial reimbursement.

[ML in VA 0]

So I'm not alone!!! Yeah! Its great to hear from someone who has gone through a similar experience. I am so excited to have this done and still plan on going after the insurance companies for some reimbursement. Please let me know how you make out!

[JamieNP 20]

Get a sleep study done. Chances are you have sleep apnea. Tricare should still pay for it.

[Cadets71 1]

ML in VA,

You more than meet the Tricare guidelines! So, I would call Tricare and ask to speak to a supervisor in the authorization department. While you may not meet CIGNA's requirements - you certainly do meet Tricares and Tricare is approving people with your stats...so it seems a little discriminatory to me. I am a Tricare beneficiary and have worked with Tricare for years. Good Luck!

[ML in VA 0]

ML in VA,

You more than meet the Tricare guidelines! So, I would call Tricare and ask to speak to a supervisor in the authorization department. While you may not meet CIGNA's requirements - you certainly do meet Tricares and Tricare is approving people with your stats...so it seems a little discriminatory to me. I am a Tricare beneficiary and have worked with Tricare for years. Good Luck!

Thanks Mary. I actually did speak with a Supervisor this past Friday. My surgeons office contacted Tricare as well. They are saying since I was denied due to not meeting "Cigna's requirements I will not be approved." So bottom line is...if I could dump Cigna..I'd be approved!! This is exactly why I am going to push hard for SOMEONE to reimburse me. What a nightmare!

[snowbird 2]

Talk to your PCP again. Your blood pressure is totally normal? Blood sugar? Cholesterol? No joint problems whatsoever? No acid reflux problems at all? See if he will order a sleep apnea test. If your PCP isn't on board with helping you, think about changing doctors. My doctor interviewed me at depth and documented my weight history through the interview (no other evidence) and went to bat for me totally. The result was that my BCBS federal plan reimbursed me for my Mexico surgery and I had to pay less than $1000 out of pocket. Good luck.

[jmichele251 0]

you know that the lap-band can you file it on your taxes and get your money back..i know many people who got there money back with there taxes....so maybe you can try that too..i know that my doc. was telling me about it..