Question:
was denied benefits for gastric bypass but it is not the same procedure as lap band?
My insurance co BC/BS of Illinois PPO denied me for gastric bypass even after I hired Walter Lindstrom. My question is: My surgeon submiited for pre-approval for a RNY gastric bypass procedure that they denied. Do you think it would make any difference if technically I wasn't getting a bypass procedure done but decided to try the Lap Band? I was told that I "do not meet the medical necessity guidelines in use by the plan". My BMI is 47.5 and I have high cholestoerol, diabetes, arthritis, thyroid problems,asthma, carpal tunnel, on and on I could go. The Lap Band is not a bypass procedure. Should I re-submit asking for pre-approval for this? Any thoughts are welcome! thanks — Janice B. (posted on March 22, 2004)
March 21, 2004
I am not an attorney, nor do I work for a health ins co, but, it is pretty
common knowledge that RNY (gastric bypass) is WAY easier to get approved
for than the Lap Band. Lap Band is still considered experimental by a
majority of Ins Companies. I only know this as 2 of the 3 dtrs in the
group I go to perform Lap Band and they say there are only a few ins
companies that approve Lap Band!
— heathercross
March 21, 2004
I agree with Heather. Most people find the fight is the other way around -
ins. will approve RNY gastric bypass before the Lap Band. You need to find
out exactly what their requirements are. If you have already appealed using
a lawyer, you might be looking at self-pay. Good Luck.
— Ali M
March 21, 2004
FIRST I wanted to comment on being denied. That shocked me.. I havent
checked BCBS 'medical necessity' lately; but if YOU dont qualify then they
have changed 'requirements DRASTICALLY in the last few years. YOU more
than qualify as 'medically necessity' according to the NIH. hmmm I would
APPEAL the medical necessity ... you have walter Im totally surprized at
this. As for the second; I wouldnt think it would 'work' The lap band is
considered WLS. and IF your insurance is paying for it they h ave the SAME
qualifications as the RNY.
— star .
March 22, 2004
I would not think so. Lap Banding is newer and sometimes considered
experimental, therefore not approved as readily. However, I would take a
look at WHY don't you meet the guidelines of medically necessary? What can
you do about MEETING those requirements or fighting them? Good luck to
you!
— LMCLILLY
March 22, 2004
Did you submit enough documentation for your comorbidities. Just stating
that you have them is not enough for insurance companies. You need to give
them lab and x-ray reports. Include list of your meds and the yearly cost.
You can get drug cost from Walgreens.com.Also send them a list of visits to
your MD and what problems were addressed.Hopefully your lawyer has already
done this. Keep after them. Insurance often deny people on the first try.
Let them know you are not giving up. Good luck.
— Linda Dianne E.
March 22, 2004
This issue is likely one of two things. Your employer has an exclusion
built into your policy or you do not meet their new supervised diet
requirements. Ask for a written copy of those medicaly necessity
guidelines, as you do meet them, but only if you have a plan that covers
and you have met all of their "other" requirements. Do you know
precisely what documentation was sent? Was a detailed diet history sent?
If not, then that can be a deal breaker with BCBS. I have BCBS of WI and
they came back and asked for that as my surgeon didn't feel it was needed.
Once I sent them that and a spreadsheet I had of my whole medical history
of diseases etc., I got approval in 1 day. However, this was in late 2002.
I do not know if WI has also added the supervised diet requirement. They
may have had it when I got approved but whatever I provided for them was
acceptable. I also had just been diagnosed with moderately severe sleep
apnea which I'm sure did not hurt my case.
<p>Of the things you list, really only the diabetes and arthritis, if
in weight bearing joints, is a factor. Have you been tested for sleep
apnea? You need to get to the bottom of whether you are being denied
because you truly don't qualify and if so get the requirements or if you
are being denied because your policy provides no coverage due to your
employers request. Good Luck, but don't give up yet!
— zoedogcbr
March 22, 2004
First are you sure that your doctor submitted your paperwork for RNY and
not the lap band? I do believe that BCBS considers lap band as experimental
and is not covering it. I find it strange that BCBS would deny you for RNY
with a BMI of 47.5. I have heard lately that BCBS of IL PPO is denying for
not having doctor supervised diet trys. Call BCBS yourself and find out
exactly why you were denied. There have to be other reasons why you were
denied.
— ChristineB
March 22, 2004
In answer to your question about any difference if technically you weren't
getting a bypass procedure done and then had lap band - that is called
insurance fraud. Be real careful what you ask your doctor to do with your
paperwork. You could be jeapordizing his/her career and you could end up in
the poky (jail).
— ChristineB
March 22, 2004
I would appeal again including the info suggested in the other posts. Then
be sure that you send the appeal to the President of the insurance company
and to the insurance commisssioner of your state. Be sure the appeal letter
states you are sending it to the insurance commissioner. It's amazing what
effect that has. Good luck.
— catleth
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