For anyone whose insurance is denying a band to ds revision...

StephOinAZ
on 7/15/11 6:52 am

I just wanted to post this info because I know there are some frustrated bandsters out there who want a revision to the DS but their insurance is denying them. (I'm going to also post this on the revision board.)

My insurance (BC/BS of AZ) denied me 4 times for a revision because it was not found to be medically necessary.  I could get into the laundry list of reasons that's not true, but I'm sure you all know the typical complications. 

I had had enough so I decided to apply for the DS and JUST the DS and see if they'd approve me, and they did.  So I worked it out with my surgeon to self pay the band removal portion of the surgery and let the insurance company cover the rest.  As much as it SUCKS to have to self pay any portion of it when it SHOULD be covered by my insurance, not having to deal with the back and forth, the appeals, the fighting, the waiting, the crying when it gets denied again is SO worth it. 

Just as an example, St. Luke's hospital is charging me just around $3,700 for my out of pocket self pay cost for the band removal.  Then my insurance responsibility is about $1,200, so my entire out of pocket expense is going to be around $5,000- assuming nothing more needs to be done during my surgery.  It's going to hurt my bank account, I'm not going to lie, but $5,000 for a 2nd chance at life, to accomplish all my WLS related goals, to finally have this CRAP band out of me once and for all...TOTALLY worth it! 

18 days until I join the dark side! 

(deactivated member)
on 7/15/11 7:31 am - TX
That's great Steph!!  Congrats!   In a few years you won't even miss that $5K
honeybadger 11
on 7/15/11 7:36 am - FL

I also have spoken to my surgeons office about seperating the 2 procedures just in case i cant get them to approve the removal of the band. At first they said that wouldnt be possible but when i explain to them about your case, that insurance approved the DS but not the removal of the band they understood better and said there shouldnt be a problem:)

I just found out the esophageal dismotility wont show up on an EGD and that it has to be an UGI and since that is the one of main reasons (beside slippage and erosion) that they will remove it, im off to get that procedure done also!

Good luck to you hun, im so happy that you will have this terrible crapband out of you soon!

~Jennifer
Revision to DS 11/9/11                                  LapBand 12/2006
SW  321/ CW 248/ GW 185                           SW 330/ HW 348/ LW 300
Join me here: http://weightlosssurgery.proboards.com
        

(deactivated member)
on 7/15/11 7:36 am
Hi Steph,

As a former employee of a health plan, I wanted to give you this tip - once the surgery is over, have the physician document all of the issues surrounding the band that he/she encountered during the surgery ie adhesions, scar tissue, etc.  Then submit a claim to the insurer on their claim form with the amount you paid asking for reimbursement.  When they deny (they will deny) file an appeal and a "peer to peer" review.  Still may not work, but these would go in favor of the patient about 40% of the time.  30% is better than the 0% you have now so it might be worth it!

Did that plan pay for the band to start with?  If not, your chances go down to about 20-30% but still better than 0%!  Also, have a conversation with St. Luke's and make sure they are only billing you the BC contracted rate for the band removal and not the "self pay" rate.  It is usually MUCH lower.  If not, ask them if they would take that as payment in full or if they are unwillng to do that, ask if they will take a little less than the $3700.

I hear ya regarding self pay.  I seriously had to pay thousands of dollars to get this crapband and if my surgeon finds even ONE adhesion or lots of scar tissue, I'm getting a lawyer.  I got the stupid thing because it is marketed as "less invasive".  Scar tissue and adhesions negate that argument.  

Okay, I'm off my soapbox now.  :)

Best of luck with your surgery and your fight with the insurer. 
nightowl
on 7/15/11 8:19 am - Topeka, KS
Thanks for the info.  (I'm not in need of it myself, but good to know.)
StephOinAZ
on 7/15/11 8:37 am
Wow thanks for this information!  I really don't expect anything but that would be absolutely awesome if it works out.  I will be sure to talk to my surgeon about this.  I appreciate this a lot!
nightowl
on 7/15/11 8:20 am - Topeka, KS
Way to go!!!!  At least it is so much better than having to entirely self-pay.
(deactivated member)
on 7/15/11 12:22 pm - San Jose, CA
I would like to amplify on this a bit: once you request a procedure and it is denied, you have VESTED your right to appeal.  You can self-pay for it, and still go back and appeal the denial, ALL THE WAY TO EXTERNAL MEDICAL REVIEW.  THAT is where you are most likely to get the denial overturned, and to get reimbursement for at least some of your expenses.

So, all you self-payers out there, if you submitted and were denied, you can STILL go back and try to get reimbursement later, AFTER you have had your surgery and are on your way to health.  It might not happen, of course, but if it does, it will be the icing on the cake.

And in this case, as the other person noted, you will also be likely to have more ammunition for the appeal when the surgeon gets in and finds something wrong, as I'm sure he will.
StephOinAZ
on 7/15/11 2:40 pm
Oh that's wonderful information Diana, thank you!  I am absolutely going to try to get reimbursed after my surgery.   I'm prepared to get nothing, but like you said, if I can get even partially reimbursed it would be a huge bonus.
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