Discouraged and frustrated...this insurance situation is going to make me crazy!!

I was submitted to insurance and denied in 4 days...was resubmitted for a physician's review before an actual official appeal and was told today that was also denied. So my dr's office is trying to schedule a peer to peer review with my Dr. and the insurance company next week.

Does anyone know how the peer to peer review works? Will they find out soon after that if I am approved or denied again?

I am looking into other options like out of country surgery and self pay. My husband keeps telling me that this does not mean that it is not happening but just delaying because it will happen eventually....just feel like I have jumped through so many hoops already and now more hurry up and wait. 

I know there are no magic answers...just disappointed and want to move forward in my journey!!

If you don't mind sharing, why were you denied?

I am having a revision from lap band to RNY...they denied because they said I was non-compliant. Which is not true because I lost 80lbs with the band until I started having issues and had to have the fluid taken out. 

I work in healthcare. When I see denials, they are often due to missing information. There is a time limit in which the doctor's office must submit the additional info.

Peer to peer reviews entail the medical director and your doctor (in this case your surgeon) discussing your case.

I would do a couple of things: First, call the insurance company and talk to the review nurse. Make sure they received everything they needed. Find out if the process was followed correctly. Four days is quick to deny something. Call the surgeon's office and talk to whatever staff is in charge of submittal. Are all of their ducks in a row?

It being submitted for physician review before an official denial was issued suggests to me information was missing.

good luck

So sorry you are having problems with your insurance company. I did not have insurance when I had surgery. Mexico was the best option for me. My surgeon that I ended up with is an excellent one at that. He taught at UCLA doing RNY. I was a complicated case and he had no problems correcting problems I had and doing the surgery, all laprascopically (sp?). If you end up doing that feel free to contact me. I still communicate with my surgeon on occasion. He is a wonderful man, both my husband and I were really impressed with him and so was my pcp (he had freaked out when I told him what I was going to do until he researched the surgeon).

Sandy,

Thanks for the info .I am definitely thinking about going to Mexico if I can't get it approved here. I have heard some good things about several drs there. I will be in touch when I find out what is going on here!

Thanks again,

Where in NC? Me too. Only it's not my insurance - that all approves first try. I heard today that the Doc in Las Vegas doesn't want to do the GBP on me because of meds I've already stopped 1 1/2 weeks ago and do not plan to start back on, because they will cause ulcers in my pouch. Why would I start a med back that would do that, much less I didn't want to take it to begin with so I stopped with my Rheumatologists blessings????

So I wondered if you were near me. We could visit and cry in our protein shakes!!!  LOL!

Ann,

I am in Raleigh. It seems like there is always something isn't it! My hubby is going through the process also and is having his lap band taken out Monday and having RNY on Dec. 3rd. I am living vicarously through him until I can find out what is going on with insurance!

Keep in touch and let me know what happens with your issues.

Okay, maybe I can help!

I am in NC also and I was denied and my peer to peer was denied.  That is simply where your doc calls up and talks to the medical director in charge of reviews and tries to convince him/her that you should be approved.

Then if you are denied you can submit your own appeal.  That is where I was finally approved.  I was denied for non-compliance of the diet regimen and no evidence of pouch dilation.

I sent in a lengthy story of all of my weight loss efforts. Seriously, like a life history ... many many pages. I included before and after I had the band and explained all the problems I had,

I also had my nutritionist notes sent in. They said that I was cleared for surgery and understood what it mean to eat after
RNY.

I then submitted a spreadsheet of my weight that I had kept.

It would also be good to send in any medical records that you have from other docs, especially ones that show you lost that weight eating like a bandster.

Do not give up on insurance yet!! Not without your own personal appeal. 

Did they deny both the removal and the RNY or just one part?

Take it to the next level before you go paying out of pocket.

Sherrie,

Thank you for the info. They just denied the RNY but approved taking out the band. I am hopeful that my dr can convince them to approve during the peer to peer but I am already getting things together for the appeal process if I have to go that road.

I have evidence that I had issues with my esophagus, my hematologist thinks that I need this, I saw a cardiologist that thinks that my blood pressure is elated because of my weight, I have sleep apnea and am morbidly obese...just have to get my ducks in a row for the appeal.

Thanks for the support and I will let you know what happens!

Take care,