Denied

[khelm32 52]

After all this time and an appeal, I have been denied. My BMI is 40 and I have asthma. After all this preparation the ins is telling me it is because my employer is self insured so they dictate their own policies. I am now being told that I do not qualify because I would have to have had a BMI of 40 for two years prior. They are not counting my asthma as a comorbity because they have a specific list of those. These qualifications are new to me. None of that is in my policy paperwork or was discussed when I called to get the qualifications prior to beginning this process. I'm kind of at a loss right now because the nurse coordinator is telling me that at this point there isn't anything I can do except to self pay, which I can't afford. Has anyone else out there had this experience?

[dawalsh 919]

I'm really sorry. Is there anyway that your PCP or any doctor appeal again on your behalf and say it is medically necessary? As frustrating as it is keep on trying. Good luck!

[khelm32 52]

They appealed it once. I'm going to go to my doc and see if I have sleep apnea. I've never been tested for it and that is one of the qualifying comorbidities. If I don't have that, I think I will be out of luck.

[MiniMi 1,468]

They appealed it once. I'm going to go to my doc and see if I have sleep apnea. I've never been tested for it and that is one of the qualifying comorbidities. If I don't have that' date=' I think I will be out of luck.[/quote']

That is how I got qualified. My dr said it is the easiest diagnosis to get because every obese person has a form of it.

[Marycusa29 60]

I know how you feel. I was just denied too. After I went thru all they requested. They said medical necessity. So we are appealing it. Dont give up!!!!

[dragonflylvr21 161]

I am a teacher and my school insurance denied me because the do not cover any weight loss surgery ever! They will pay for diabeties care but nothing to prevent it! Crazy! My husband has federal insurance and signed me up for his and I was approved! I was banded the 24th and had to pay a portion out of pocket because they didn't cover it all! Good luck!

[JULESDARLN 26]

I am not sure what state you live in, I live in Arkansas and they have a state program here called Arkansas Rehabilitation Services that is helping me pay for mine. I think every state has a program like this, you just need to do some research. If I did not have insurance, they would have covered 100% of it. So if you end up having to pay out of pocket, try to look into this. Sorry you did not get approved.

[khelm32 52]

I went to my primary on Tuesday. I have an appointment with the neurologist on Tuesday regarding the sleep apnea test. So we'll see how that goes.

[bluegirly 343]

Good luck! It's terrible when you are dealing with insurance! I fought for almost a year and I was still denied. I appealed, then it went to a second level appeal, and that was it. I'm lucky enough to be able to pay out of pocket, but it was still crushing to be denied. I'm trying to look at the cost as an investment in my health. Keep us posted!

[littlebare 10]

I would keep appealing until u got approved. What insurance do u have? Bc I have blue cross blue shield and they approved mine really quick and I'm not as over weight as some ppl. My BMI is 35 but in the past 6 months I've been put on high blood pressure, cholesterol, meds and borderline diabetic. I was actually surprised when they approved it. I really didn't think they would but my doctor was confident they would.

[khelm32 52]

I had my appt with the sleep doctor last night. I'm scheduled for the sleep apnea test next Friday.

I have United Healthcare. They are telling me if I have sleep apnea or diabetes I would qualify even though my BMI is over 40 now. I've been tested for diabetes and do not have that. Otherwise they are saying I would have to have a BMI of 40 for 2 years. If I don't have sleep apnea then I will try getting on my husbands insurance and go from there.

[annanyc 33]

A sleep apnea diagnosis sounds like the path of least resistance and I'd definitely continue with that- fingers crossed for you!

But if there's no 2 year >40 BMI requirement listed in your policy terms, and assuming United has no discretionary right to deny coverage even if you meet all the requirements, I'd fight the decision. Just because you've exhausted internal appeals, doesn't mean there's not more to do. Insurance policies are contracts. You and your employer are paying the premiums and it sounds like United isn't honoring the bargain. And the involvement of a lawyer, or at least a firm assertion of your rights, may be a good option here. Many times, whether car, home or medical insurance, first level attorneys and administrators are pressured to deny expensive claims to save money, because valid or not, if you create enough hoops, only so many people will jump through them.

Kind of like me waiting on hold for 75 minute to cancel Time Warner Cable tonight. In the end, it just wasn't worth it, and though I'm even less happy with the TWC tonight than I was last night, they got what they wanted. I'm still paying for the product.

[JulesfromE17 11]

I got denied as well, I have Cigna ... but they denied it for lack of adequate dietary information. They finally approved it and I've now been banded almost a month, but I devastated Don't give up .. keep trying. Dr's and their practices are usually really good about helping you work through denials. Their job is almost to find reasons *not* to pay. Good luck, keeping my fingers crossed for you.

Sent from my Samsung Galaxy S3 using LapBandTalk

[khelm32 52]

A sleep apnea diagnosis sounds like the path of least resistance and I'd definitely continue with that- fingers crossed for you!

But if there's no 2 year >40 BMI requirement listed in your policy terms, and assuming United has no discretionary right to deny coverage even if you meet all the requirements, I'd fight the decision. Just because you've exhausted internal appeals, doesn't mean there's not more to do. Insurance policies are contracts. You and your employer are paying the premiums and it sounds like United isn't honoring the bargain. And the involvement of a lawyer, or at least a firm assertion of your rights, may be a good option here. Many times, whether car, home or medical insurance, first level attorneys and administrators are pressured to deny expensive claims to save money, because valid or not, if you create enough hoops, only so many people will jump through them.

Kind of like me waiting on hold for 75 minute to cancel Time Warner Cable tonight. In the end, it just wasn't worth it, and though I'm even less happy with the TWC tonight than I was last night, they got what they wanted. I'm still paying for the product.

I agree with you. The nurse that has been helping me said there are attorneys that work for Lapband and will step in and try to assist. The problem she ran into with my insurance is that my employer is self insured, so that means they write the contract of what they will and won't cover and the insurance company is simply just administering the contract for them.... My other option if the sleep apnea diagnosis doesn't come through will be to get on my husband's insurance, but we will have to see what their coverage is for this procedure before we do that. Self pay is the last option and not one I really want to do.