Denied Insurance

Has anyone had to file an appeal with their insurance because the insurance company would not pay for lap surgery only open surgery. Some help with what I need to include in the appeal letter would be great.Thanks!

Is there a reason why you do not want to have open surgery? I had my wls open because thats what my insurance would pay for and I've never been happier .... I figured that I wanted wls and i'm approved i'm going to take it and deal with it...i've lost 117lbs so far and looking back I wouldn't have had it any other way may friend had her surgery 2 weeks before me she had hers lap and i've lost 55lbs more than she has not too sure if its because i've had mine open but thats what my Dr. says is the reason. Good luck with your fight

I thought I had wanted my procedure done lap, until the whole thing was explained to me, then I decided I would MUCH rather be open so there was manuevering room in there. At 278 pounds I wanted my doctor to be able to see everything easily. I was back to work in two weeks even with open, and I didn't have any of the associated 'gas' pains that come with being 'blown' up for lap. Good luck with your appeal. Hugs, Mo

my procedure was laproscopic and bcbs paid for mines. or are you asking about the lap band procedure? i wish you luck in your wls journey. i know bcbs is not paying for lap band surgery.

don't freak out about having open surgery...I was a self-pay and I wanted open rather than lap....i know folks all have an opionion based on their experiences.....personally, I wanted the procedure that carried the least risk...that was open vs lap...although I had my surgery about 16 months ago and some docs now have 16 more months of experience....I would do open again without hestitation. best wishes, RAE

Thanks for your post to my denied insurance question. I am afraid of the open surgerical procedure because of my medical problems and the extended recovery time. Locally I have heard some pretty bad stories pertaining to the open procedure. Thus the reason I choose a surgeon and a hospital 125 miles from my home. WLS was a difficult decission for me and after much research I felt I wanted laproscopic surgery. Continued sucess to you all and thanks again. I will keep you posted.

Terri, Depending on your specific BCBS policy (e.g., CareFirst, Federal, or through some other BCBS franchise), I have heard how they are inconsistent in their approval of lap vs. open RNY surgery. How they can continue to argue that the lap style of surgery is "experimental" is beyond me, given the state of medicine. Unfortunately, the Maryland statute that requires, under certain conditions, coverage of gastric bypass surgery, does not specifically mandate that the patient must be able to choose from the lap or open style. However, you may wish to contact the Maryland Insurance Administration (MIA) office to find out whether a company such as BCBS can decide under which cir****tances a patient may or may not have their surgery lap style. Even if it's too early for a complaint to the MIA (usually you first have to exhaust the appellate procedure through your insurance company), they may be able to advise you in this regard. Good luck. Keep us posted. Leesa

I'm most likely going to have to be self-pay, but you should definitely fight for what you want. The worst they can do is say no. If my insurance would only pay for open and I couldn't get them to change that decision, I'd probably go self-pay. Looks like there are quite a few people who didn't mind having the open. If they deny you laparoscopic, I guess you must really think through the reasons for why you want to avoid open surgery and make a decision based on what's worth more to you. Sit down with a pen and make the old + / - list.

BCBS refused to do my RNY as a laparoscopic procedure -- requiring it to be done as an "open" RNY. After three appeal letters with supporting documentation (letters from my surgeon, citing articles and research studies) they finally conceded that laparoscopic was appropriate in my case -- just 3 days before my scheduled OPEN surgery. I found that it often depends on the doctor *****views your case. One of the MD's for BCBS routinely rejects lap, while the other allows them. Keep on them. It took me five months, but I'm glad I persisted. GOOD LUCK!