I have Highmark BCBS of PA and I was denied :think because it's experimental/investigation. has anyone have the same and have been approved? please help me:help:

Have you read the brochure they should have given you?

They did not send a brochure, I read at the web site and it was revewed back in April of 2005, They pay for the gastric but not the band.

They do pay for the band, they paid for mine and I know of at least 2 others. Do you by any chance have rail road insurance? ~Mandy

No I have Highmark Blue Cross Blue Shield witch I thought it was all the same and they tell me is not, there are many different BCBS company's

I have highmark BCBS and they had the policy of not paying for the band. I am the first to have a lapband paid for ever with that company. You will have to fight it, unless your employer has it in their policy not to cover it. If that is the case then appeal to your employer. See who is not covering it, the company or the employer and then fight from there. I am willing to help if I can, just let me know. ~Mandy

Mandy

Thanks for replying employer does cover, as a matter of fact she's all for that. on the policy states tat anything that is under investigation is excluded, I have my denial letter and the doctors office say that it's all up to me. that all I can do is wait until they review the policy again and it's taking out of investigational.

but now if it's not to much to ask what did you do? did you appeal? how long did it take you? and what did you have to do to be eligible to be covered or to get approved?

I have posted a few times about the issues I'm having with my denial from BC/BS. I work for a company who is headquartered in PA so even though I live in MASS and work in CT, my insurance is HIGHMARK BCBS OF PA.

My denial sound about the same as yours. The denial letter states:

that I am not eligible for reimbursement because the” surgery has been determined not to be medically effective for the condition being treated and therefore is considered experimental/investigative in nature”

It goes on to say that a procedure is considered to be experimental/investigative if:

• The intervention doesn’t have FDA approval to be marketed for the specific relevant indications;or
  
• Available scientific evidence does not permit conclusions concerning the effect of the intervention on health outcomes; or
  
• The intervention is not proven to be as safe or effective in achieving an outcome equal to or exceeding the outcome of alternative therapies; or
  
• The intervention does not improve health outcomes;or
  
• The intervention is not proven to be applicable outside the research setting.

I was then provided with the medical policy bulletin that states:

There is a lack of peer reviewed medial literature that contains comparative data that demonstrates that Lap Band is equivalent to or offer any advantage over the accepted standard of vertical banded gastroplasty or Roux-en-Y gastric bypass.

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Does that pretty much sound like your letter? They will give me RNY surgery on any day of the week but Lap-Band is a NO GO!!!

I was also denied because I needed 6 months of nutritional and excercise consulations that were overseen by an MD. I have finished those and I'm also continuing to go just in case 6 months suddenly changes to 8 or 9 months if they deny me again. They are very underhanded these people.

I am formulating my appeal and will have it ready to go out by the end of this week. There primary issue is that they feel that RNY is more effect and the gold standard surgery. I am attaching with my appeal all sorts of research that comes close to challenging that assertion. I have to admit that in all my research I never came across the sentance "in conslusion, we find Lap-Band to be equally or more effective for the treatment of morbid obsitity then RNY". I would've loved to..but I couldn't find anything. So, I will appeal, keep my fingers crossed and then....if that doesn't work....I'm changing my address and getting differnt insurnace.

The kicker of all of this is that if I live a 1/2 of a mile down the road in the state of CT my employer would have me covered under CIGNA and our CIGNA plan covers Lap-Band. Yup...I just don't get it. I am paying the same amount of money as the person I work with for the same coverage but I have Highmark and she has Cigna and she is going for the surgery and I'm not. It really is enough to make me want to cry. I really wish you the best of luck and hope that we can both finally get what we so badly need, deserve and want.....a life free of being morbily obese!!!

Take care,

Gina B.

Hello, I work for a Lap-Band Dr. and I have experienced the same denial's several times, we just appealed with the FDA approval information that you can get from inamed

Gina, contact the HR dept at your work and let them know that you don't have equal coverage fo equal insurance payments. I know that is what finally helped me get covered. We have the choice of highmark or United Healthcare and the UH covers the proceedure but the highmad did not. My husbands employer was not aware of the difference and they made highmark pay for the proceedure. There is a CD that you can get from Don Mills that has all the long term studies and the FDA trial results on it, just call Inamed and ask for him they will give you his voice mail and he will get back to you. He is great and was very helpful in my appeal process. It took me 6 months to finally get approved but it was worth the effort. I was denied 3 times and getting ready to go to an outside appeal company when I got my husbands employer involved. I was covered within 4 days after getting HR and the union involved. Feel free to contact me if you have anymore questions or if I can help in anyway. ~Mandy

Mandy:

I have been had my employer involved since day 1 of the denial back in April. They haven't been of any real help. They say they see the difference but don't really say what they are going to do about it.

I am the HR assistant at the location I work for and this is my email communication between me and the corporate benefits specialist.

Can you read it and see what you think they are trying to say? To me they are just saying "Yup, we see the difference but you are going to have to bark up the Highmark tree and not ours".

Thanks for reading...sorry so long.

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Hi Gina,

Alcoa Benefit Services reviewed the communications from both Cigna and Highmark. Its has been decided that you should file your first level appeal with Highmark as indicated in the letter dated 4/25/2006. We can see the differences between both Cigna and Highmark. Cigna stating approved procedure based on criteria met, and Highmark stating not approved because procedures are considered experimental/investigational.

There should be clear and concise information that supports what is consider experimental/investigational. I would suggest submitting Cigna's Coverage position with your appeal.

Lynda:

Thank you very much for getting back to me. I am compiling my first level appeal letter packet this week and mailing it to Highmark. Since I have now completed the 6 months of nutrition that was requested in the denial letter, I just have to prove to them that the procedure is not experimental/investigational. Not an easy undertaking I'm afraid. I'm told from Inamed, the makers of the Lap-Band, very few people have been able to overturn a denial with Highmark that was based on the experimental/investigational stance. Highmark is one of the last hold out insurance companies not covering the band.

That said, I did want to mention that what I'm most confused about is that fact that the policies vary. The fact that coverage isn't uniform between policies within the same level of coverage seems unfair. Maybe I am not clearly understanding the "self-insured" aspect of our policy. If I am an employee that has chosen Coverage Level X and I live in Mass, shouldn't I have the same coverage as a person with the same plan who lives in CT? If so, that's not how these plans are working. If I lived in CT, this would be a moot subject because our Cigna policy covers Lap-Banding. I was told by both Highmark and Cigna that Alcoa determines what is and is not covered. Highmark does not cover Lap-Band as a rule due to their medical review boards determination that the surgery is investigational/experimental, however, their rep told me that all Alcoa has to do is to tell them to cover it and it would be done because, being self insured, Alcoa determined what would and wouldn't be covered in the first place.

Could you please explain why the differences exist?

Thank you.

Gina Breen

Hi Gina,

I certainly understand your point. I must tell you Alcoa does not decide what is covered and what is not. Alcoa purchases a plan from Highmark and what is covered is based on medical necessity as well as procedures that are considered approved by the FDA. I do agree that we should not be seeing differences in benefits offered under Cigna and Highmark, having said that, I hope that your appeal points out the differences between the two carriers.

Keep me posted.

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My husbands employer called and Highmark covered it. But the HR or Insurance dept must be the one to make the call. They will not overturn the expermental decision at all without that. The other option is to appeal, appeal appeal and then you have the right to an outside impartial board to review your records, I was told that if you meet the critera for the band it will be overturned by the outside review board. They make the decision based on the fact that you need the sugery and the fact that it IS FDA approved. The HR or insurance dept can overturn the decision with a single phone call, I know that is all it took for me. ~Mandy

Hello Group

My name is Len and I'm in California. I'm new to this group and trying to figure out how to post a question. If I'm not in the right section, can someone help?

My insurance (Blue Shield HMO)has recently approved me for a consultation for bypass surgery. I went to Cedars Sinai Hospital and met with a wonderful doctor, Gary Furman. He recommends the Lapband for me. After hearing the facts on the two options I really don't want my "innards" cut up and disected. I would like to have the lapband surgery. In looking at my insurance brochure, it seems as though they approve the bypass but not the lapband which seems ludicriss to me.

I would REALLY appreciate some advice.

Thanks

Len

Some insurance companies deny the band as they list it as investigational. I fought and won with our bcbs company. Call and ask what is covered and what is not. You will need to billing codes that your doctor will use and also the diagnosis code. The billing depatment and sometimes even the front desk can give you these codes. Best of luck. ~Mandy

nukempi: if you do a search on this site, I think it's Alexandra that has a GREAT example letter out there on why the band's better than RNY. It may be worth a search!