Lookin for help, anyone know the way?

angiekay78 · March 20, 2006

Just wanted to drop a line as a newbie :confused: I seem to be stuck in weight loss limbo and could really use some advice. My insurance will not cover Lap Band surgery stating that it is experimental. However, they do cover gastric bypass. Fortunately, the surgeon I have been seeing believes that I am an good canidate for either surgery. That doesn't really make me feel better, though. I want to make a well informed choice about which surgery to choose. Frankly, I don't want to feel forced into a surgery that is more invasive and therefore more dangerous when Lap Band can be another option. I have spoken to a rep form my insurance on several occasions and have been pretty let down. I know that there is an appeals process I can initiate but no one will give me the information on how to begin. I even sought some online advice from attorneys who will help with the filing but all with large fees. If I had that kind of money, I would pay for Lap Band myself and save the heartache of dealing with my insurance at all. Anyway if anyone can direct me down the right path, I would really appreciate it.

Mvpo8961 · March 20, 2006

AngieKay tell us who is your insurance provider. Someone may have that same one and can give you some insight. M:D

Alexandra · March 20, 2006

Angie, I was in exactly the same boat and you absolutely do have options.

The only way to appeal an insurance denial is to have the denial in hand, though, so you must have your surgeon put in the request in the first place. If he thinks you're a good candidate for bariatric surgery, your file is probably complete, right? So have your surgeon go ahead and put in the request for precertification for lap band surgery.

Once you get your denial you will be provided with appeal instructions. You have to be, by law. This is absolutely something you can do yourself. If the reason for denial is that the band is experimental, that's easily appealed since the band was approved almost FIVE years ago now.

Anyway, that's your first step: get your request in and see what happens. If you're denied, the next step is appeal but come back here first for help. Your denial letter should have very clear instructions about what to do. And you may not even be denied! It's entirely possible that your carrier will have a different attitude than what you're being told now.

Good luck!!

angiekay78 · March 21, 2006

Thanks so much for the replies, it is nice to know that there are people willing to help you when you are faced with a situtation that will potentially change your life. I live and work for a contract rehab company in Western KY, however I have Anthem BCBS of Alabama. I have had many dealings with them as I have had several trips to the ER for kidney stones and ovarian cysts. They have been wonderful in paying those claims. In the past couple of years I have been hospitalized for my overian cysts, had lithotripsy for my stones, and underwent a hysterectomy. I am so thankful to have medical/health insurance at all, but have really been disappointed with their help in this matter. Again, they have told me that through the proper guidlines gastric bypass would be covered. I have attended seminars, met with my doctor of choice, and completed some of the initial testing and have been seeing a dietition on a regular basis. For now I have put the remainder of the procedures on hold. Just passing time hoping things may change with my insurance.