Help Appealing Experimental Investigational Denial

GinaB · July 28, 2006

I received a denial letter from Highmark BC/BS on March 25th . I was denied because they deem the band procedure as experimental/investigational. They contend that RNY is more effective and has better long term results…yadda, yadda. It’s nothing that we haven’t heard on this site a million times before.

Since my insurance company is self insured, I have been fighting with my HR department, to no avail, to get the policy changed. What is so outrageous to me, is the fact that if I lived in a different state (5 miles from my home) I would have Cigna and the policy would cover it. I happen to live in Mass and therefore my company offers Highmark BC/BS to people in MA. Highmark is a Pennsylvania based insurer. My company, Alcoa, is headquartered in PA. So, the bottom line is, if I lived in CT right now I would be banded and all this denial BS would be behind me.

So, now that I’ve rambled in frustration…..let me get to the point. Does anyone have documentation or anything that supports the use of Banding over RNY? I know that this is the type of information that will help me with the appeal. Any info would be terrific.

Thanks in advance.

JulyBandster · August 2, 2006

Hi Gina - just wanted to let you know that I also was denied for investigational purposes - by Anthem Blue Cross/Shield of CT. They are very known for doing that the first time out.......I hired a lawyer for under $500 and he did an appeal in about 3 weeks - and I was approved! So all is not lost. The lawyer that helped me was steve kalman and he has the band himself. He doesn't live near me - lives in PA, I think - but I learned of him from another bandster who had been in my situation. I emailed him my info then we went back and forth - he decided if he had a chance or not...then got on it! I'm thrilled - anyway - his email/website is bandedlawyer.com.............good luck!

ralheit · August 2, 2006

I don't get it. I have Anthem BC/BS and was approved in 3 weeks. I just figured that if you had BC/BS and it approves some people, it would approve everyone. But I guess it is up to your employer as to whether they allow the band or not. It sucks. Hope you have a successful appeal.