need more help!!!!

dell · April 7, 2005

Hi,

Guess Yall Are Tired Of Hearing From Me!!!! But Called My Insurance Carrier Today.. Said That They Have Recieved The 46

Pages Of Paperwork From The Lap Band Coordinator. They Tell

Me I Have An Exclusion On My Insurance About Lap Band Surgery.

Even If I Have Paperwork. Theytalked Like It Wouldn't Be Reviewed.

I Haven't Recieved A Denial Letter. I Don't Know What To Do!!!! Very

Upset About This.. Maybe Somebody Can Help Me As Far As This Goes

And Tell Me What To Do .... Appreciate All Of Yalls Help. Hope And Pray Somebody Will Help Me. Hope To Hear From Yall Soon.

Love , Dell

donali · April 7, 2005

I am no insurance guru - I'm sure Alexandra will post and tell you to appeal, appeal, appeal. I have also heard that you should go ahead with all the jumping through the hoops for whatever WLS your insurance DOES cover, and then once you're qualified for that, demand the procedure of your choice.

HOW to do this, I cannot say! But don't give up hope!!

Alexandra · April 7, 2005

Dell, your next step will depend on several things. You should get a denial letter from the carrier specifically outlining your appeal steps.

Get your contract and read it carefully. MANY policies say they exclude "treatment for obesity" but go on to say that treatment for MORBID obesity is covered. Do you qualify under that standard? Find out exactly what is excluded and why. Is it all treatment that's excluded? Just surgery? Just this kind of surgery? Why?

Once you know the answers to these questions you'll be able to plan your next step. You should also investigate your state's rules about HMO plans and whether you have any right of external appeal. Visit your state's website for that info.

Read, read, read! Talk to your employer's human resources person and find out who designed your plan (is it one of the carrier's standard plans? Or did the company pick and choose the features?). You have not lost the battle, you've only just found out that there will be one. But all is not lost!! Let us know what you find out, and we'll be here for you.

(Donali, you know me like a book! )

sandie1958 · April 8, 2005

what insurance carrier do you have? i pray you get a yes

sandie

dell · April 9, 2005

Sandi 1958,

Than you very much for the reply to my post and the thought. T

have BLUE CROSS/BLUE SHIELD OF TEXAS (health select) though Mexia State

School where I work. I really think I'm going to get turned down. Because I called them and was rudely told that they don't cover weight loss surgery even

if you have done all that you are to do as far as asking for it medically. The best

I can do is appeal it and hope to get it approved eventually. Sandi I have heard from alot of people through this forum and believe everyone seems to care about this whole process. I love each and everyone of yall. Someday I HOPE TO MEET SOME OF YALL. Again thank you and have a nice day or night and know that you are being thought of. Love, DEll

sandie1958 · April 9, 2005

dell; i am so so sorry you were aspoken to rudley esp. when you are down anyway . prayer can change everything i will keep you on top of my list. i wish the insurance comp. would realize we are trying to get healthier & do better for ourselves. sandie

dell · April 11, 2005

Sandie 1958,

Thank you much for the reply. I guess I do stay a liitle on edge

now. You are a very sweet person. I'm going to call my lap band coordinator

Monday. Maybe she will know what to do or help in some way. Well I start

back at Curves. That's just going to be worser for me. But I will strive on

and do what I can until somthing is approved or not approved for me.

hope to hear again from you. love your friend, dell

I'llsucceed · April 11, 2005

Dear Dell- I have Blue Care Network & am in the appeal process now. The denial letter can take up to a few weeks to recieve. In the mean time find out EXACTLY what the exclusion was like Alex has advised already. One thing I did find out from the insurance carrier I have is that its better to have the DOctor write the rebuttal in somecases because it may be reveiwed faster. I also found out depending on how busy the Doc is you may have more time & can just ask what should be said in the letter. From there they usually have 30 days to tell you they have recieved it & they will respond back.

I wish you so much luck- I feel that this is the worst part of the whole process!! I have already been trying to find ways to self-pay these past months just in case. Patience is a Virtue. But it soooooo hard. Best of luck to you!

dell · April 11, 2005

:cry I'LL SUCCEED,

DEAR, THANK YOU FOR THE REPLY TO MY POST. I',M

JUST WAITING FOR THE DENIAL LETTER, WHICH I SURE WILL COME.

I'M GOING TO LOOK INTO ALOT OF THIS ALEX AND YOU ARE ADVISNG ME TO

DO. BUT I HOPE YOU GET YOURS. LET ME KNOW HOW IT COMES OUT ABOUT THE APPEAL. thank you,

yours truly, dell

April 20, 2005

Dell, just think you should look at exactly what your policy says. I have BCBS of Texas (select choice) and it says there is an exclusion on:

"Any services or supplies provided for reduction of obesity or weight, including surgical procedures, even if the Participant has other health conditions which might be helped by a reduction of obesity or weight."

Now if we could call the LapBand anything but what it is, but ultimately, BCBS will say that it is a procedure for weightloss. I even went to Obesity Law and Advocacy, and exclusions are one area that they do not like to do.

Anna

leadiaz · May 11, 2005

FYI - As of May 1, 2005; I heard Carefirst Blue Cross Blue Shield is covering lab band surgery. I called my insurance company and they said they do. Let me know if you heard this. I heard it from a nurse at a lab band office.