Jump to content
×
Are you looking for the BariatricPal Store? Go now!

Went to the appeals board today...



Recommended Posts

It looks really bad-- everyone was great except this lawyer they had there she had every reason under the sun why they shouldnt have to cover it. Some of them were just plain untrue--- she tried to say that the band and the high number of complications related to the band is more expense the the cost of obiesity!:) She has no clue- I am a nurse- I see people with heart attacks, stroke, cancer and diabetes everyday run up hundreds of thousands of dollars in one hospitalization. It really seems like their mind is totally made up before you even appeal. I should know their answer with in a week but I am sure it in NO WAY, So I have to figure out what the next step is. I am going to look into Indiana's Dept of Insurance and see what I need to do to file a formal complaint and get an independant appeal board to look at the case. I could just cry..... I dont know what to do to lose this weight-- I have tried everything

Share this post


Link to post
Share on other sites

Jill, I am so sorry! Don't give up. I wrote one of the owners of the company my husband works for (he is an email buddy of mine) and asked him why they don't pay for WLS and he said that since they are self-insured they cannot afford to and that they try to provide insurance for things that employees don't have any control over. In other words, I should be able to control my weight on my own. He did send me Gov. Huckabee's book though and it was very inspirational. I am still not giving up though. I will wait until I get on Medicare in a few months and try them. LOL.

Sharon

Share this post


Link to post
Share on other sites

Jill -

Of course their attorney had every reason why they shouldn't have to pay. That's her job.

Chances are good that they will say "no" if that was not an INDEPENDENT review board.

Find out what you have to do to get and INDEPENDENT review - I had to go to the State of CA - and you may have to go to the State of IN. It's all part of the process. In the mean time, YOUR job is to collect documenation to argue all the points that the insurance attorney erroneously made. Get some statistics on paper regarding the cost of a hospital stay for a heart attack, or the cost of long-term diabetes care vs the cost of the band surgery and related complication rates & expenses.

The numbers won't lie. If you are currently taking medication that could reasonably be expected to go away if you lose the weight - stack the monthly cost (to the insurance co) of the meds you are taking against the cost of say, 3 fills a year. State Review Boards love documentation.

Keep your chin up! Go get 'em.

I am keeping my fingers crossed for you.

Share this post


Link to post
Share on other sites

JillRN look at Cigna's Healthcare Coverage Position Statement for Bariatric Surgery. There are a number of references that you could pull for your appeals. Go to www.cigna.com and do a search for 0051 this will pull up an alphabetical list. From there go down to bariatric surgery. They have a 20 page position statement on BS with 88 references. You should be able to pull some of there references to support your case. M:Bunny

PS anybody with BCBS insurance should look at the references that Cigna uses from BCBS Technical Evaluation Center. It might help with appeals also. M

Share this post


Link to post
Share on other sites

Many of you have followed my saga trying to get this surg approved and my appeals-- THank you for your support! I was denied by Anthem for my second appeal. I am insured through my dh and they have always covered the surg until Nov 1 the same day my paperwork was submitted they excluded anyway ON TO THE GOOD NEWS!!!! I found out my work is covering it for 1000-1500 dollars!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! :) I dont have the insurance at my work though, I am PT but they said if I go FT I can pick up the insurance then I would be covered. I have been thinking of going FT b/c we need the money right now, but I would probably want to drop down to PT again next year or maybe even next fall. Is this ethically wrong?? I can still keep the coverage PT I have to pay more (which I will keep it b/c I will need it for fills right??) I am so excited I feel hope again for the first time in a while! I need this pray it works out ANyone have WAUSAU?????? thanks again you guys have been so supportive!!!! JIlll

JACK-- YOUR ARE SO COOL_THANK YOU!_ I AM GOING TO KICK SOME BUTT--I AM GOING TO KICK SOME FAT BUTT AND LOSE MINE!!!!

Share this post


Link to post
Share on other sites

Congratulations Jill; that is fantastic news!

Share this post


Link to post
Share on other sites

JillRn I have been an RN for 23 years. Although presently I am a SAHM while homeschooling my 15 y/o. No it is not ethically wrong to flip to FT then when you need to go to back to PT. They are paying YOU for your talents and work not the other way around. Insurance is part of the TOTAL compensation package. My husband is an ICU manager and this is how they look at ins as part of the total compensation. You are a valuable asset to THEM. Go for it and be HAPPY. M

Share this post


Link to post
Share on other sites

Create an account or sign in to comment

You need to be a member in order to leave a comment

Create an account

Sign up for a new account in our community. It's easy!

Register a new account

Sign in

Already have an account? Sign in here.

Sign In Now

  • Trending Products

  • Trending Topics

  • Recent Status Updates

    • BeanitoDiego

      I've hit a stall 9 months out. I'm not worried, though. My fitness levels continue to improve and I have nearly accomplished my pre-surgery goal of learning to scuba dive! One dive left to complete to get my PADI card 🐠
      I was able to go for a 10K/6mile hike in the mountains two days ago just for the fun of it. In the before days, I might have attempted this, but it would have taken me 7 or 8 hours to complete and I would have been exhausted and in pain for the next two days. Taking my time with breaks for snacks and water, I was finished with my wee jaunt in only 4 hours 😎 and really got to enjoy photographing some insects, fungi, and turtles.
      Just for fun last week, I ran two 5Ks in two days, something I would have never done in the past! Next goal is a 10K before the end of this month.
      · 0 replies
      1. This update has no replies.
    • Teriesa

      Hi everyone, I wrote back in May about having no strength. I still get totally exhausted just walking from room to room, it’s so bad I’m using a walker with wheels of all things. I had the gastric sleeve Jan. 24th. I’m doing exactly what the programs says, except protein shakes. I have different meats and protein bars daily, including vitamins daily. I do drink my fluids as well.  I go in for IV hydration 4 days a week and feel ok just til evening.  So far as of Jan 1st I’ve dropped 76 lbs. I just want to enjoy the weight lose. Any suggestions or has anyone else gone thru this??  Doctor says just increase calorie intake, still the same. 
      · 0 replies
      1. This update has no replies.
    • Stone Art By SKL

      Decorative Wall Cladding & Panels | Stone Art By SKL
      Elevate your space with Stone Art By SKL's decorative wall claddings & panels. Explore premium designs for timeless elegance.
      · 0 replies
      1. This update has no replies.
    • Clueless_girl

      Losing my hair in clumps and still dealing with "stomach" issues from gallbladder removal surgery. On the positive side I'm doing better about meeting protein and water goals and taking my vitamins, so yay? 🤷‍♀️
      · 0 replies
      1. This update has no replies.
    • BeanitoDiego

      I've hit a stall 9 months out. I'm not worried, though. My fitness levels continue to improve and I have nearly accomplished my pre-surgery goal of learning to scuba dive! One dive left to complete to get my PADI card 🐠
      I was able to go for a 10K/6mile hike in the mountains two days ago just for the fun of it. In the before days, I might have attempted this, but it would have taken me 7 or 8 hours to complete and I would have been exhausted and in pain for the next two days. Taking my time with breaks for snacks and water, I was finished with my wee jaunt in only 4 hours 😎 and really got to enjoy photographing some insects, fungi, and turtles.
      · 1 reply
      1. BabySpoons

        Amazing! Congrats!!! Watch out for the sharks. 🦈

  • Recent Topics

  • Hot Products

  • Sign Up For
    Our Newsletter

    Follow us for the latest news
    and special product offers!
  • Together, we have lost...
      lbs

    PatchAid Vitamin Patches

    ×