My first appeal was denied before they even got my paper work or appeal letter. It was denied based on me saying "I want to appeal, send me the forms" They sent then but sent me the denial before they really even received the forms based on the new "exclusion" they inacted the day my surgeon requested the procedure. hmmm these people are really shady-- so now I am going to stand before their board of appeals with their Dr's RN's and lawyer and such. I am not a bit intimadated at all-- this is probably a good thing b/c they wont realize what is coming at them is a strong, determined, and educated person. I think my Dr is going to join via conference and I may have a lawyer present if I can find an affordable one. Anyone have experience with this????

I did this via conference call. I wasn't intimidated, but it quickly became clear that they had absolutely no intention of even considering a chance in their policy based on anything I had to say. The panel consisted of one nurse, one doctor, and one administrator (I think) from the carrier. The doctor had the courtesy to pretend he had read my information, and even made a comment or two about how "the literature" was piling up in favor of the band. But ultimately all three of them were on the carrier's payroll and they had their predetermined agenda to follow.

It wasn't until someone OUTSIDE the carrier got involved that I had a chance. I hope your state gives you that opportunity if you are denied again. Good luck!!!

I broke down the insurance monster after 10 months of having one hissy fit after another. My policy (BCBS self funded policy) was sitting on my paper work trying to put me off until after December 31st, you know, so they could add an exclusion to the policy. I got the Labor Board of Texas and the companies Insurance Policy Administrator involved. Trust me, the insurance company didn't like the Labor Board snooping around thier procedures. BCBS wouldn't give the Labor Board any answers because of HIPAA, but they knew they were on to them. Simultaneously to them getting involved, my husband called the appeals department (without my knowledge) and talked to the lady I'd been dealing with all those months and kept her 45 minutes after hours pleading with her to help. He told her lots of sweet things like "he could not raise our two boys by himself and he can not live without me". I know, he's kinda cheezy, but that really is how he is. Three days later, I was approved.

Im glad you are not intimadated by them after your insurance primiums pay thier payroll, They work for you when you look at it this way. I would call the insurance commissioner of you state and ask them how to handle an Insurance Co. that doesnt follow due procedure, You might get approved because they broke the law for not following documented procedures. Very biased and illegal. They may have just opened the door completely foryou on just this one issue.

P.S. I would also ask them if they are ready to take responsibility for any future health issues or even death since you have had a Dr. request this procedure for you and They denied it.