After having a barium xray swallow and showing my stomach prolapsed up through the band, I was scheduled for "must-do" surgery.

Got a denial for $14,000:eek: (plus $3,000 from anesthesiologist) for everything.

Doc sent an appeal saying it was an emergency, had to be done, couldn't live with the band that way, etc... Also stated I had been slowly losing, until the surgery, and now that I'm not at my sweet spot, has gained a couple pounds. This basically shows that I NEED a working lap-band® in me to keep from gaining the 90 lbs I had lost.

Well, now they approved the removal, but DENIED the replacement band. Apparently, my bmi is 39.9 (needs to be 40 to be covered or between 35-39.9 with a co-morbidality) and I'm too SKINNY for the replacement band to be covered.

Doc is putting in a 2nd appeal. For some reason the hospital and anesthesiologist never sent their own appeal (I thought the doc doing it was enough, but it isn't).

What do I do? Is my credit going to get all screwed up? The $14,000 bill from the hospital was 30 days overdue on Dec 5th... I called and told them we have asked for an appeal.

My husband and I are beside ourself. I am scheduled for a fill on thursday, but I don't want to go because I don't think they will cover that either! The good news is my new insurance (BCBS PPO) starts Feb 1st, and I think fills should be covered because it's a medical device that's already in me?? (but there is a $1500 deductible per member, and $3,000 per family) My current insurance is United Healthcare.

Any suggestions? Do I need to hire a lawyer?:rolleyes2:

Oh and the total kicker is the hospital didn't weigh me the day of surgery... they asked me how much I weighed.. I said 217... (last dr's visit").. However, it was more:unsure: (since I got unfilled because I couldn't swallow my own spit. then I could eat more), but I said the lesser number because I didn't want my surgeon to be upset that I gained a few pounds ...

Brenda

Just an update -

Insurance FINALLY paid the bill ($21,000 total) after multiple denials, and doctor sending new requests for coverage.

Most insurance companies just keep denying patients hoping they will give up. DON'T - keep fighting, cause in my case, we won. :thumbup: WOOOHOOO!

Did they pay for the replacement as well?

Your post hit home for me. I also have UHC and had a prolapse. I meet with my doctor tomorrow to look at my options.

Yes, they finally paid for the removal AND the replacement after multiple denials, and asking for more information. The total ended up being $21,000. I even sent them a fax with everything I went through explaining that I had to have it put back in or I would gain all the weight back, and end up back on high blood pressure meds, a c-pap, etc. In the long run, it would save them $$ by keeping me healthy!

Good luck with your appt tomorrow. I was contemplating doing a gastric sleeve revision, but my doctor had only done 1, and we didn't have enough time to get approval. So, I figured if the lap-band has another issue, I'll change it then.