Advice about Appealing my Insurance Denial!! Help!!!

I am gathering all my data for my appeal to Highmark BC/BS and was looking over my denial letter today. It states that I am not eligible for reimbursement because the" surgery has been determined not to be medically effective for the condition being treated and therefore is considered experimental/investigative in nature" It goes on to say that a procedure is considered to be experimental/investigative if: ? The intervention doesn't have FDA approval to be marketed for the specific relevant indications;or ? Available scientific evidence does not permit conclusions concerning the effect of the intervention on health outcomes; or ? The intervention is not proven to be as safe or effective in achieving an outcome equal to or exceeding the outcome of alternative therapies; or ? The intervention does not improve health outcomes;or ? The intervention is not proven to be applicable outside the research setting. I was then provided with the medical policy bulletin that states: There is a lack of peer reviewed medial literature that contains comparative data that demonstrates that Lap Band is equivalent to or offer any advantage over the accepted standard of vertical banded gastroplasty or Roux-en-Y gastric bypass. What I would like to know from you kind folks out there is where can I find this data? All the data I can find on the internet states that Lap Band is not as effective and I know that's not completely accurate. If you are looking at short term weight loss ..yes, it's more effective but overall I think less risk with the same results is equal to the safe IS MORE EFFECTIVE!!! I just can't find any documentation that would state that. I certainly can't make a statement and then state that is was from "The Annals of Gina Breen's Mind". Don't think the medial review board would take too kindly to that. Any help or advice would be terrific. Thanks, Gina B.

Gina, I am sorry, I don't have the answer for you. I have heard that it is harder to get Bands approved. Good luck, my prayers are with you! p.s. you may want to post this on the lap band thread too. ~chrissy

I had BC/BS of CT and they approved my band - My husband's FED BC/BS did not pick up the copay ($250) but that was ok Try an appeal Betty