Help!!!

[myangel 0]

I just got denied from my insurance(amerihealth hmo) telling me that they approve gastric bypass if medically necessary but do not approve gastric banding.........has anyone else had this experience?...what should i do??

[princess_n_thep 2]

Hi carolyn. Can you tell us a little about yourself in introduction? Welcome to Lap Band Talk!!!!

[the best me 6]

My BCBS is the same, bypass fine if medically necessary. Lap Band is excluded. I paid cash and went to Mexico!

[myangel 0]

I am from new jersey and have been researching lap band for about a year and finally made my decision that this is the way to go and then I got all the consults needed and paperwork completed and submitted it to the insurance company to find out that they are denying the claim.......I am soooo upset about this!!

[the best me 6]

It's very dissappointing. I get so frustrated with insurance I knew I didn't have the patience, perseverence, or even hope that I could fight it. Maybe I could have if it were covered but they didn't find it medically necessary for me, but with it being so clearly excluded, I didn't even go there or try. I'm really sorry.

You don't have to go to Mexico to pay cash. Do a search for self-pay, or cash pay and see what you find. There is a thread about the Wish Center in Chicago doing band surgeries for $10,500 I think. I paid $8950 plus airfare and expenses. There is another doc in Texas that does them for 11 or 12K?

I know you don't even want to go there...pay cash when you have perfectly good insurance (well, maybe not! ) . Your other option would be to somehow get on with another plan if possible, or find out when you insurance is reviewing the policy for exclusions and wait and see if they will eventually cover it. That could take years? Just be sure if you bother to change plans, the new one covers Banding.

Do some searching around in here, you are sure to find some things to help. Or. just ask!

[myangel 0]

thanks sooo much for your input.it helsp to share your feelings with someone who can relate...what happens when you go to another state and need the fills?

[the best me 6]

It's a free-for-all!!! kidding

The fill issue and aftercare is a big one, especailly for MX folks but also if you go out of state. The BIG rule is to be sure you have a local (as close to home as possible) Band doc who will see you after having surgery somewhere else, whether in the states, MX, Belguim, or wherever. That's usually a big rub. I found one about an hour+ up the highway from me and feel fortunate. I would love to see my band doc in MX but I live in North Carolina, yes, the opposite side of North America, so the airfare is a bit much.

You obviously have a local doc you have been working with. Would he or she see you and provide your aftercare if you were to go to, say, Texas for the surgery? You can always ask...make sure you have a band surgeon in mind when you ask. They might be more willing to say yes to a US doc, Inamed certified, etc. than an unknown MX doc with potential for liability problems. You have no real rights when you go out of the country, so that decision is not for everyone. For me, I love my Band surgeon. He has loads more experience than most US docs and an impeccable reputation so that made it better for me.

Surf around in here. You will find plenty of entertaining and informative reading! And keep asking questions!!

[KarenB 0]

Carolyn, what's your BMI and where do you live? I do know of a low BMI study (under 40) taking place in Westchester NY for $12,500 total.

[the best me 6]

Woohoo!! Lookie there!

[Alexandra 55]

Carolyn, I had the exact same experience with Aetna, which totally excluded the band based on it's being "experimental" back when I was trying for approval. I took it through the two internal appeals and then went to the state--the great State of New Jersey guarantees HMO members the right of external appeal when there are decisions we don't agree with.

Long story short, I WON!! Please don't give up. If Amerihealth has approved you for bypass you have a VERY GOOD CHANCE of getting that decision overturned on appeal. They have already decided you are a good candidate for bariatric surgery, so what is their reason for denying banding? Have you appealed yet?

[myangel 0]

thanks sooo much for your support.......my bmi is 44 and I have not appealed yet. I am waiting for the denial letter first..I have filed a request for help with obesitylaw.com but I am trying one more thing with my insurance before I take action.......wish me luck and thanks again!!!!

[myangel 0]

you are not going to believe this but I WAS APPROVED FROM MY INSURANCE!!!!......I am soooo excited but on the other hand want to throw up because now I am so nervous about the surgery......I am scheduled for June 6th..............

[the best me 6]

Oh my gosh!!!!!!!! WOW! I'm blown away! Well good for you! :banana :banana

If those bananas don't turn out, sorry, but I'm dancing for you! Way to go! Do you know why they changed their minds? A well placed letter? What happened?

Put your boots on, girl, June 6 is a'comin like a freight train!!

[myangel 0]

well.believe it or not..they were conflicting stories between reps at my ins co.when I called and when my surgeon's office called........one said I had the benefit and the other said I did not.....they did not even ask for medical information and denied the case....it was then turned over and requested medical information.after fighting with them.....I was then approved the next day...-this morning!!!...I was all ready to file with obesitylaw........

[the best me 6]

Aw right!! Way to go, I'm so glad you got approved, just took the right person with the right info with a little push in the right direction, huh? Yippee!!! I'm going to do some more dancing bananas for you cuz I can. It worked last time! Yippee!!! :banana :banana