Insurance problems

Hi. I am a canidate for LapBand surgery and my insurance is telling me that I have a Direct exclusion on my insurance. Keep in mind.... I picked my surgeon and also had my consultation aswell as my psych eval. I had a consultation when I met with the nurse, the surgeon, and the dietician. That following week I had got an appointment with the other doc for a psych eval, and he approved it- but now...... I have to wait on the Bariatric center to submit all my information to my insurance aency and that will take a few weeks before they decide. So, today I took it upon myself to call my insurance agent and guess what..??? They din't care about anyone ir anything so they told me NO this insurance is taking care of it. Guys... I am totally bummed out, the only thing I can do at this point is nothing and wait for the final NO.

I went through alot of obstacles with the lap band, and although I was approved for it, in the end I opted for the RYN. It's a very new procedure, this is why some insurances/employers are not covering it. I was one to say I would NEVER alter my insides and get the RYN, TOO invasive, but I too was up against the wall and had to make a choice. I got tiered of waiting and had a change of heart. Insurance said yes, but because it was so new, I needed another person to be approved and have surgery the same day as me so the surgeon could be "proctored." Everyone else got denied so I couldn't have my surgery until someone was approved! RYN in september, no regreats.

Thank you Jessica for your response. The thing is with me is that my insurance is not covering WLS period!!! I don't know what to do. i don't know if I should appeal it or what. What to do on that note? and the RYN......I am definitely afraid of. What comps did you have with lapband?

Is this because you are not "medically necessary?" As I said I know for sure the employer is the one who tells Wausau what it will and won't cover so you may want to check on that. I never had to appeal but I do hear it works almost 99% of the time and people are approved on their second try- however, this would only be if there were something wrong with the pre authorization (the stuff your clinic sent in) if your employer is saying weight loss surgery in general is a direct exclusion, you are stuck like chuck hun. I actually was completetly agaisnt the RYN because I thought it was entirely too invasive for my age and I wasn't super morbidly obese or anything, but part of my insurance complication with the band had to do with the fact that it was so new- which worried me more. There is ALOT of upkeep, constant adjusting of the band, inflate, deflate, it just seemed like too much to deal with. Also I did my research, I don't want to scare you or push you in any direction so I won't tell you any horror stories or negative info, I will just say I was the Band poster child for almost a year, after being approved in June, I changed my mind in August and was so completely comfortable with my decesion, my heart was totally in it.

Well Jess,Thank you for your response. Something has to give. My Doctors said that this is necessary. They wrote a letter of necessary to United but I guess they don't care.... I don't know. Are there other options?

Hey TK, well you can continue to appeal or pretty much find other coverage. Insurance is such a huge part of the whole battle, good luck!

You absolutely have to appeal. They seem to automatically deny (in my opinion). It took me 18 MONTHS of pure insurance hell before they would approve my Vertical Banded Gastroplasty. Be very careful to read EXACTLY what they want, exactly what they are saying. It could be that they won't do the LapBand. I'd asked for it initially and THAT particular procedure CIGNA would not ever approve. I switched the request to the VBG, still had to go through tons of other crap, but ultimately did gain the approval. It was a very long, and very difficult fight. But one that was SO WORTH FIGHTING! I was denied, and also denied on appeal. I was at my absolute last time and that's when it came. They were requesting a peer to peer consult with my PCP, and before it could even happen, they just said OK! I don't think I've ever been happier about anything in my life. --Well, up until now. I've lost nearly 150 pounds since then (10/04) and after being denied and denied on appeal AGAIN, United Health Care told me that my only hope to have the excess skin from my abdomin removed was to ask my husband's employer to make an exception to their "cosmetic surgery exclusion." Well what did I have to lose? I wrote the most compelling letter that I could, attached (disgusting) pictures and prayed a lot. I thought I'd pass out when I got a letter that said they agreed! I am having an "Abdominal Lipectomy" (tummy tuck) done in two short days! (PLUS as an added bonus, Dr. Chua will remove any fat that he comes across along the way!) So hell yeah, you have to appeal. You have to fight! Harder than you have for anything. It certainly isn't easy, but I promise you it is well worth it! Best of luck to you, Julie