Denied for lap band removal and new surgery - new doctor - attorney involved help

My insurance denied my band removal saying that even though I can't tolerate it, it is functionally fine. I have NO fluid and choke on food daily, have severe reflux that IS controlled by Prilosec, but the 10 years of Prilosec (I've had my band that long), has caused my stomach to be full of polyps. But because it's not "broken" they won't pay for its removal. I'm also trying to revise to a DS or Sadi-Loop. Even though my BMI is 56.9, they said there is no need for Bariatric surgery. So I hired an attorney (Lindstrom) and OMG it's taking them FOREVER to get the appeal together. Add to that, it took my surgeon's office 3 WEEKS to send them my files.  I hired them on June 30th and no appeal has been sent yet.  I've already paid them $700 of the $1000 that they charge. I have literally been jerked around for MONTHS (from everyone). I jumped through everyone's hoops (all my psych stuff and dietetics are done) and whatever else they asked for. I started this process in November 2014 and was hoping for surgery in May or at least early summer as I'm a full-time student. I'm 49 and have a TON of health problems, all related to obesity and I have PCOS. Every day I find new things wrong with me because of this excess weight. Last year I gained 80lbs (5-7lbs a month) because of a medication that we didn't know spiked my insulin through the roof (which already runs high normal to begin with). I finally found information on the net and figured out what was wrong. Once I went off of it, I stopped gaining but am now 80lbs heavier. So here it is, school starts next week, and no surgery. I also have an $8000 deductible that I have all but met due to all the preliminary stuff. In fact I'm almost to my stop-loss and at least part if not most of my surgery will be covered at 100%. That gives you an idea of how much I've spent trying to have this surgery. Now I find out my surgeon hurt his wrist on vacation last week and will need surgery to fix it. They not only don't know/or won't tell anyone WHEN he's having it, but can't give us an idea of when he'll be back to surgery. I can NOT have this go into next year. It will bankrupt us (new $8000 deductible starts again).  So I was thinking of switching surgeons. The surgeon I originally wanted to go to is 2 hrs. away, which is what made my decision to not use her originally.  I had my lap band at this hospital and LOVED it there (the one that is so far away).  Now I have a whole lot of friends that are happy to drive to appointments with me (my husband was having to take off all kinds of work to go with me - he would still go to important ones, just not every single one). She is the only doctor in the state of Indiana that does the original DS (Duodenal Switch).  I was told I may wake up with a sleeve only (by my original surgeon).   I am supposed to have a “phone testimonial” on September 10^th with my attorney, BCBS and I. It’s a type of “appeal”. My original surgeon failed to include a YEAR of monthly appointments I had with a hormonal weight loss doctor that also did an entire shake/pudding type of diet program as well. That may be why they said I didn’t try enough because that wasn’t included (from Jan 2013 to March 2014).   OK, so if you made it to the end, boy do I appreciate your continued interest. Here are the questions. I know some of you have used attorneys and I believe someone told me that they used Lindstrom before. Did it take as long as this to get things going? What do you suggest I do about the attorney/new surgery submission?  The new surgery will be coded completely different. Should I have the new surgeon submit a new surgery precertification request and I tell the attorney to sit on hold in case I need them (I am happy to finish paying them as that is what I promised to do. OK, not happy, but understand my responsibility). Or should I have the attorney send the newest surgery in from the beginning, knowing what they know about the law in regards to my surgery? Or do you think they’ll say “too bad so sad, new surgery, new $1000”.  Keeping in mind they have not submitted anything for me yet. I’m supposed to get a call back on Monday to set a consultation appointment with the new surgeon. I figured once I set that appointment, I’d call the attorney and tell them what’s going on. Honestly, I can’t wait around for the other surgeon to ‘get better’ especially having NO idea how long that will even be, oh and every person approved before me goes on a list before me. One quick note. I had a regular doctor’s appointment yesterday and she said “Perhaps the whole reason this has taken so long and nothing has gone through is because you aren’t supposed to have it locally and should be having it with this other surgeon 2 hrs. away.” The surgeon far away has a LOT more experience.

Thanks again!

Have your surgeon do a Peer to Peer with the insurance...My surgeon did it for me, They approved the sleeve but not the removal of the empty band and flipped port...Come to find out Cigna (my secondary who was fighting this) had an OBGYN deny me...My surgeon gave them an earful...I was approved the same day!

Yeah, we had a Gastroenterologist do my peer to peer. He even said "I don't know why they sent you to me, I'm not a bariatric doctor. I'll forward your stuff to appeals". But I'm looking at going to a new surgeon as mine has hurt his wrist and needs surgery and they have no idea when he'll be back to surgery.  SO FRUSTRATED.

Yvonne

I would guess Lindstrom won't be doing anything until they are paid in full then they will start the work depending on how many are ahead of you. Are you positive the insurance covers the surgery it sounds like they have denied everything so far. Nor all insurances cover revisions. I wish you the best tho, I had a band so I know how miserable they are.

Lindstrom said they would process it as soon as they had everything. My surgeon's office took over 3 weeks to send them my files. I have a phone testimonial with Lindstrom and BCBS on the 7th of September. Yes, they do cover it, just they are so stubborn about paying for things in general. Thanks for replying!

Good to hear, in that case I'd say just keep pushing be the squeeky wheel and make them listen to you!

I'm so sorry you are going through this. I have no advice or experience in this, but wanted to offer support. Stay strong.

Oh boy...we have lots of similarities....Have you had an upper GI with barium,Endoscopy,and ct scan???If so it may uncover other band related issues to add to your case.

Had an Endoscopy which he said looked fine from the inside, other than I have a "field of polyps" in my stomach from 10 years on Prilosec due to terrible reflux from the band. But not the other ones. I'm looking at a new surgeon, so I'll ask her about that. She may already suggest those anyways.  She's pretty well known for getting things approved.

Wow, I feel for you.  The thing is that if there is nothing functionally wrong with your band or something like a slip, dilation, erosion etc., insurance need not cover band removal at all . . . you certain your surgeon didn't miss a diagnosis like this?

The second thing is that insurance does not have to pay for a revision. . . . your insurance covers more than 1 Weight loss surgery per lifetime?

Can you Sue the pharmaceutical company that forced you body into gaining such an extreme amount of weight in 1 year.  If that weight gain can be proven directly linked to a medication, certainly they can be sued as that rapid gain in such a short period can trigger diabetes, heart disease, increased cholesterol levels, hypertension etc.

Sorry you are going through this.  I hope it all comes together for you soon.

All best