insurance horror

August 13, 2003

Called my insurance and was told they do not pay for such surgery...interesting that they will pay for me to be ressected! as is done with the other type of bypass surgery....

anyone else been told the lap is not insured, then to appeal and have success? I have not submitted, just called...

Any others paid out of pocket?

Thanks, Amy

NetteInBoulder · August 13, 2003

Isn't that ridiculous? From what I understand, the bypass is a much more expensive surgery, not reversable, and higher complication and mortality rate and so many insurance companies are still only paying for that! Hopefully, as there is more research about the effectiveness (not to mention the cost effectiveness) more insurance companies will get on board.

That rant aside, don't give up yet. I called my insurance (Pacificare HMO) back in November/December '02 and they said they would only pay for RNY and VBG and specifically not the band. I kept going on with my research and made an appt with my PCP, got him to give me a referral to the only doc in my area who was doing the band who was in their system, even though they said they woudn't do the band. By the time I had my consult with him (3 months later- he had a long waiting list) Pacificare was approving Lap Bands and they paid for the whole thing!

On the other hand, not all insurance companies are getting on the bandwagon so quickly. If you need help in getting an approval, be SURE to visit the BandstersInsurance email group webpage on yahoo.com. Look up in their files and database for their suggestions, sample letters, sample appeal letters that have worked, and last but not least, the contact info about the attorney in CA who has helped a lot of MO patients get their insurance companies to pay for WLS.

One more resource I just remembered! On ObesityHelp.com, look up the webpage of a woman named HeatherM who is in Colorado, a patient of Dr. Johnell I believe. She has an AMAZING story about how she got her insurance co to pay for WLS (not the Band though) through her hard work. It's inspiring!

Good luck!

Annette

Alexandra · August 13, 2003

Hi Dramy,

My insurance carrier, Aetna, also excludes the band specifically. I was able to have their denial overturned by going through the independent review process guaranteed by my state's insurance regulations.

Before going there I had to go through three internal appeals, all of which were flat (and very fast) absolute denials based on the band being "experimental." I don't believe Aetna ever got past that policy to actually look at my medical situation. And everyone considering the appeals there is, obviously, on Aetna's payroll, so they were bound by that policy as well.

But when an INDEPENDENT reviewer took a look at the situation, the decision came down that the band is not experimental and that it is appropriate in my case.

Call your state's department of insurance and see if they provide for any third-party review of managed-care decisions. You'll have to exhaust your carrier's appeal process, but if they exclude the band completely that process should go quickly.

seanmama · August 30, 2003

Thank goodness I looked on this page! You guys are so helpful. Annette I am going to Yahoo right now! I too have been denied - by United health care.

Seanmama

September 16, 2003

So far I have had luck with Pacificare HMO. They approved an eval with a surgeon after my PCP asked them to. I have everything scheduled and all I pay it the copay portion. I am told they will cover the band under certain circumstances and my surgeons office will submit the paperwork Nov 3rd. I am nervous but optomistic. I research my surgeon as well as other patients that had the same insurance and was told they were approved in just a few days. Keep the faith!

Sophia:)