SURGERY DENIED AFTER PEER TO PEER
I NEED HELP DON'T KNOW WHAT TO DO NEXT. DOCTOR'S OFFICE CALLED AND TOLD ME SINCE THERE'S NO LIFE THREATENING PROBLEMS THEY WILL NOT COVER THE REMOVAL OF THE BAND SO THERE IS NO REASON FOR ANOTHER SURGERY..I NEED AND WANT TO FIGHT THIS. IT'S DOWN RIGHT DISRESPECTFUL TO SAY THE BAND HAS TO STAY IN AND WHAT WAIT FOR SOMETHING TO HAPPEN TO IT AND THEN THEY'LL COVER IT?? I NED HELP WITH AN APPEAL LETTER OR SOMEONE WHO HAS WENT THROUGH THIS I'M SO UPSET AND SAD AT THE SAME TIME ANY INFORMATION WILL BE APPRECIATED
well you didn't say why you were denied? you have to understand unless there is medical necessity then explant will not be paid by insurance payment unless you have a rider, as it is not medically necessary. when I had my band the man who had it the same day, had it removed, he could not long stand having an object inside of him, but he too had no health issues, so he was self pay for explant. if you are still MO, you could attempt to appeal that way, as you could appeal on the basis of the band is not a long lasting effect MO treatment and has the highest re-operation rates of all surgery types. Before you contact anyone for legal service, double check your subscriber agreement you have to preserve your dates, and how many appeals you have, if you exhausted all your appeals, no appeal, no letter, no attorney can help you. you have to know your rights in order to fight. good luck with your journey..It is a very rough path...
I posted on your other thread before I saw this.
I had documentation to prove medical need to have the band removal. I had a totally band unfilled at one year and two years with a scope the first time showing inflammation of the esophagus and gastritis. They left it unfilled for 6 week the first time and 8 weeks the second time. Also I had the band unfilled when throwing up and filled when I could eat anything. The last 9 months with the band I had an unfill every month as the scare tissue would make it tighten.
The key is documentation. You have to make sure they record EVERYTHING that you discuss with the surgery center and PCP. When going over my medical record, I found the techs didn't write everything down. I than made sure the techs, RN's and PA's wrote everything down each and every time I went. I was able to prove the band had to come out for Medical Need. Than I had the surgery notes and photo of my stomach to prove the problems the band caused and that I was compliant.
That I had the band out without knowing if I could have another WLS, I believe helped my case. The band had to come out one way or the other.
BAND REMOVED 9-4-12-fought insurance to get sleeve and won! Sleeved 1/22/13! Five years out and trying to get that last 15 pounds back off.
I had similar problems and fought for ages to get a band to sleeve revision. Insurance company said no to band removal (even with documentation) said no to revision. After a year I finally got them to pay for removal but no sleeve. I am paying cash on the 28th. I cant tell you how much I wish I had called lindstrom Advocacy as soon as I got the first denial. They are AMAZING! Affordable and they know everything and everyone who deals with bariatric insurance issues. Please call them. It would have saved me a lot of money and a lot of hassle if I had done it in the beginning. I am sorry you are going through this. I know how frustrating it is. The insurance company makes you feel like a failure who isnt worthy of spending anymore money on. I hope it turns out good for you. Please do call and talk to Kelly at Lindstrom. She will help you out.
I am scheduled with Dr. Dirk Rodriguez in Dallas. If surgery is booked before the end of this month, it is $10,900. It doesnt have to be paid for until surgery day and you can always reschedule it but they said you have to at least be on the schedule before pricing changes. This price is all inclusive and includes up to 2 nights at forest park medical center. Its very hard to find a GOOD u.s. surgeon at that price.
