Insurance says lap band experimental and turned down!

February 5, 2004

Can anyone help me with this? Has anyone faced this? If so, can someone tell me how their journey went from there. I have Cigna EPP, and that was the response I got.

Alexandra · February 5, 2004

Hi Tayloram,

The same thing happened to me and to a lot of people, though I'm surprised Cigna has tried to pull this on you. Cigna was one of the earliest carriers to approve the bane on a regular basis.

What I did was go through my carrier's internal appeal process--which resulted in repeated denials for this same reason--and then went through my state's external review process. I ultimately won and my carrier paid for my surgery last summer.

As time goes on fewer and fewer carriers can claim "investigational" since the band was approved by the FDA almost three year ago. IMO it's the weakest of all possible reasons to deny a request for banding.

My recommendation is to appeal it as many times as necessary. you will prevail in the end. :confused:

CathyFalb · February 6, 2004

You can call Inamed and get them to send you some documentation that shows that the band is not investigational or experimental. Alot of people have gotten this response from their insurance and some have had it over turned when they submit the documentation from Inamed. Also check with the insurance again because I was told this by my insurance last year on April 18th and they satrted paying for the band on April 20th. After that I just got denied for othre reasons. I'm with a new insurance now waiting for approval. Good luck!

February 7, 2004

I was turned down by BC/BS in July of 2003. They said the band was considered "investigational". I kept checking back with my insurance company to see if their policy might change. Was I shocked when I called on Oct. 1st and was told that they just started approving it that very day. I was approved in a matter of hours and was banded on Oct. 28th.

So I am of the same opinion that it is just a matter of time before all insurances will be approving it. They cannot go on much longer saying that its experimental. There's just too much evidence to the contrary.

Good Luck, Diane

sassaay · February 7, 2004

Hi Tayloram,

I am not sure how close Cinga EPP is to Cigna HMO, but I too was denied 3 days before surgery for the following reasons:

1. Lap-Band is investigational

2. Weight loss is slow

3. Requires too much after care

My surgeon called Cigna and asked to speak to someone with some authority. Ended up speaking with the medical director and went over all the reasons why Lap-Band was better for me than Gastric Bypass. Even though I would not have gone with Gastric Bypass, my surgeon told Cigna they were pushing me in that direction. My surgeon specifically noted the cost differences between the two surgeries, the fact that complications are higher with Gastric Bypass and how Lap-Band is better for young women still in child-bearing years. This medical director approved my Lap-Band and I had surgery as planned.

Maybe your surgeon could call Cigna EPP.

Good Luck.