Question:
got denied-got denied on appeal, should i keep trying?

just wondering if i got denied and denied on appeal should i keep trying or if i try for a lap instead of rny might they approve it?    — Godsvirtuoswoman (posted on April 28, 2008)

April 28, 2008
did you get a reason why you were denied? If your insurance policy does not cover the surgeries, you are kinda stuck, but if they do and are denying your request, find out why and what criteria they require before considering settling for something that was not your original plan. Good luck
   — Jeanne Aldrich

April 28, 2008
What was the reason for the denial? Was it a lack of information or deemed not medically necessary? What does your surgeon's office say? Is it a plan exclusion? Mine was with BCBS which was why I was a self pay. I would be carefull as you only have a certain number of appeals with the insurance company. As far as which type of surgery you should have, only you know which is the right one for you. I can't remember the name, but there are Bariatric Attorneys who can get just about anyone approved from what I have heard for a nominal fee. Very reasonable rates. Good luck to you and if you meet the criteria for the surgery... go for it... let nothing stop you! Dawn Vickers, RN, BLC, CLC
   — DawnVic

April 28, 2008
HELLO, WHO DO YOU HAVE FOR INSURANCE? I HAD CIGNA WHEN I GOT GASTRIC BYPASS. I WAS DENIED 4 TIMES. EVEN THE DOCTOR CALLED AND THEY STILL SAID NO. I HAD TO FILE 2 APEALS. AFTER THE LAST ONE THE 5TH TIME I GOT A YES. THEY WOULD SAY I DIDNT DO VITALS OR THERE WAS A WEIGHT MISSING OR CHARTING WAS WRONG. SO WHAT I AM SAYING DO NOT GIVE UP. KEEP TRYING. I NOW HAVE BLUE CROSS BLUE SHIELD AND I HAVE TO DO MY GASTRIC OVER BECAUSE OF SOME ULCERS I GO TOMORROW AND GOT A YES RIGHT OFF THE BAT. SO GOOD LUCK AND IT DOES NOT MATTER WHAT YOU ARE HAVING DONE GASTRIC OR LAP EITHER ONE IS THE SAME TO UR INSURANCE
   — aluvzu2

April 28, 2008
you should keep trying.
   — soliisoul

April 28, 2008
You need to restate your request for assistance with the actual statement they give you for denial. If it is you have no Bariactric coverage, it does not matter. If it is you have no case for Medical necessity, get a good Bariatric surgeon and have him make your case in writting. Usually, RNY's are approved faster than Lap Bands as they see more medical necessaty with Type Two Diabities and High Blood Pressure corrections. If you need legal help got to www.obesitylaw.com. THey help fight insurance denials.
   — William (Bill) wmil

April 28, 2008
Keep trying. Who is your insurance company? I was denied twice and had to extrnal appeal and that is when I got my yes. If this is something you beleive in the keep going
   — Kjackson2

April 28, 2008
If I were you...I would track your insurance companies record..( this site might help..) If they just have a standard 40 + BMI rule then get your BMI to 40 before you re- apply...It's ridiculous I know but maybe the way to go! I don't think you will get better results from Lap band with your diabetes...RNY seems so promising in that area! My Doctor said there was no difference between the 2 procedures in the eyes of the insurance companies...( RNY and LAP Band that is...) Please though, for your own sake do not give up..This is life saving surgery and If you need it you should have it!!!! lots of love and you are worth it !!!!
   — [Deactivated Member]

April 29, 2008
The most important thing to find out why your where denied? If there is an issue with medical necessity and you meet the BMI requirements it may be the absence of a comorbidity (diabetes, hypertension, ect). If that is not the case and it is an issue with missing documentation it may take some time to meet their requirements but you should be able to fight it and get approved. Lastly, if you are insured through your employer you want to make sure that their contract with the insurance company does not exclude surgeries and more specifically this surgery. Keep in mind that if your physicians office does not already know the general requirements for major insurance companies you may want to look in to going to another practice that services you well both medically and financially speaking. The office staff's knowledge is paramount in insurance approvals. I do medical billing and worked with a bariatric practice for several years and we never had any one denied who met the general bmi requirements. I hope this helps and if you have any other questions please let me know. Jessica B.
   — MRS.B

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