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Insurance Denied Revision - Next Step Peer to Peer

lspringman

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lspringman    9

lspringman
Posted

I'm in a panic right now :)

I had the lap band in 2012 and started having problems, so I started looking into a revision to bypass.

I completed all the required steps the insurance requires (dietitian meetings, Psych eval, stress test, EGD). EGD even showed that my band had prolapsed. Everything was pointing to in the direction I needed to get an approval.

Fast forward 3 weeks - I get a letter from the insurance that my claim was denied!!! WHAAAT?!?!

I called the doctor's office in a panic.....They said the next step is for them to do a peer to peer with them (which is what they do for people that get denied). I do remember that I was told that revisions usually take 2 rounds of approvals. Maybe that's what this means?

Anyway - has anybody gone through this as well? I have United Healthcare. Do they typically approve after the peer to peer? I don't understand why I wasn't approved to begin with. I'm eating tums like they're candy at this point! (because of my issues, not because of the stress of not being approved LOL) UGH!!!!

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Jazzy1125    1,010

Jazzy1125
Posted

I am still new to all this, but i wish you the best of luck and that the insurance ends up approving your revision. Keep us posted!

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Ed_NW    684

Ed_NW
Posted

You should switch to prilosec or something other than tums. I ended up with kidney stones because of the type of Calcium in tums. Good luck with the insurance. It always seems like they do things like that to discourage people.

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lspringman    9

lspringman
Posted

You should switch to prilosec or something other than tums. I ended up with kidney stones because of the type of Calcium in tums. Good luck with the insurance. It always seems like they do things like that to discourage people.
I just recently started papaya enzymes and they work GREAT...sooo much better than Tums!!! I also heard bad results of taking prilosec as well (can't win for losing).

Sent from my SM-G965U using BariatricPal mobile app

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Walter Lindstrom    42

Walter Lindstrom
Posted

Hi! Stay optimistic but be prepared for UHC doing the wrong thing. The peer to peer process isn't often a great process for patients - it often starts with the UHC medical director and your surgeon having trouble connecting on the phone to even discuss things. So don't let that drag out before you act because even if/when they do connect your surgeon may be dealing with a UHC medical director who simply doesn't have the authority (or the expertise) to consider your individual circumstance. So be proactive and take control - Your best shot at overturning the denial may be the patient appeal process and you don't need to wait for the peer-to-peer to get started on an appeal. Your bariatric provider may tell you to wait for the peer to peer but you'll feel better if you're doing something proactive and know you're learning about the process. And if the peer-to-peer is successful (HOPEFULLY) than you're good to go and you've lost nothing. But you may want to call us to help walk you through things - we do a lot of UHC band removal/conversion appeals and we know their process better than anyone. Hope this helps and good luck!

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JLondon11    8

JLondon11
Posted

I have united healthcare and am revisioning from lapband to sleeve on 2/20 I am wondering if your medical group has a lot of experience with revisions, mine did and told me they knew “all the right things to say” and got approval. Hopefully your group will fight for you with the insurance company and all will work out for you... I know you are probably as anxious as I am to get the lapband out! Best wishes!

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lspringman    9

lspringman
Posted

I have united healthcare and am revisioning from lapband to sleeve on 2/20 I am wondering if your medical group has a lot of experience with revisions, mine did and told me they knew “all the right things to say” and got approval. Hopefully your group will fight for you with the insurance company and all will work out for you... I know you are probably as anxious as I am to get the lapband out! Best wishes!
They do, which makes me feel better. They seemed pretty confident, I'm just a nervous Nelly LOL. Were you initially denied as well and had to do the peer to peer? If so, how long did it take to finally get the approval?

Sent from my SM-G965U using BariatricPal mobile app

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JLondon11    8

JLondon11
Posted

No I was approved on the first pass, but it sounds like they know what they are doing, just breath and put your faith in them, will pray for all to go well for you!

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lspringman    9

lspringman
Posted

Got a little bit of good news this morning... Found out the denial appears to because of coding. They have been told by UHC to use a code that includes the removal of the band and the bypass. Now they're asking for the codes to be separate... One for the removal and one for the bypass. She's confused because UHC is the one that told them to use it! So my Dr has a peer to peer set up on Tuesday with the Medical Director of UHC.
FINGERS CROSSED 🤞

Sent from my SM-G965U using BariatricPal mobile app

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JLondon11    8

JLondon11
Posted

Awesome!!!! Crossing fingers for you!

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Ed_NW    684

Ed_NW
Posted

Good for you for being assertive. The squeaky wheel gets the oil.

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lspringman    9

lspringman
Posted

Good news, everyone!!! Peer to peer was successful! It was in fact just a coding issue! They received a verbal approval that same day (Tuesday) and received a written approval today (Friday). Surgery is schedules for 2/25!!

Sent from my SM-G965U using BariatricPal mobile app

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Go To Topic Listing Revision Weight Loss Surgery Forums (NEW!)

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    • Alisa_S

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      On day 4 of the 2 week liquid pre-op diet. Surgery scheduled for June 11th.
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      1. summerseeker

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