Medica Insurance Denial for Revision from Band to Sleeve- anyone successfully appealed?
I had a SAGB band placed in October of 2005 during the clinical trial for the device. It has stopped and I get GERD anytime the band is filled. I received a denial from Medica- I was denied because I didn't have a more major complication. Has anyone here appealed to Medica and won? Would you share your experience?
Thanks much!
Megan
Megan - can you give us a couple more stats? Like, what is your CW, what was the terms of the clinical trial (ie - once the trial stopped, could they remove it at no cost to you? etc.), how many appeals can you go with Medica (usually it's two plus a final, but call the company and verify for your specific plan), did you have your band placed by a local surgeon, have you continued following up with that surgeon so they have a documented list of your complications from the band?
Hi Diamond Girl! I meet all the requirements for surgery with my BMI, dietician visits, etc. now. I can have two appeals and then a final external review. I had my band placed by Dr. Ikraumuddin at U of M Fairview Hospital and I have continued to see him over the past 9 .5 years. I do not know if I could have the band removed at their costs- that is a great question. Otherwise, my complications are really that I have untreatable GERD when my band is filled. This is documented in my file, but when I received the denial letter, it said that "reflux from overeating" is not enough to warrant a revision surgery, or something along those lines.
Thanks for any help you can give me!
Megan
on 10/12/13 8:39 am, edited 10/12/13 3:35 pm
These are Medica's policies for revision. See page 3, middle of the page for the specific reasons they require for all revisions. I would argue for one of these reasons--first taking them to your physician for documentation along the same lines.
Pat
