Preapproved for band removal but insurance denied to pay claim after surgery.

Hi,

I was banned in April of 2009. It was great at first and I lost 70 lbs. After 5 years into it, I need to be unfilled due to relocating to my hometown to deal with issues after my dad passed away. At that tine, my how town does not have a bariatric doctor, so to be on the safe side, I got unfilled. After, I came back, I got filled again but this time all sorts of problems starts.

Pain in my left shoulder, throwing up even with unfilled, pain in my chest like heart attack, anemia, heart palpitation and so on. I did have barium test done twice but everything was okay. I got an endoscopy done and the doctor have to stretch my esophagus.

After 8 long years, I cannot take it anymore, so I went and talk to my surgeon. He agreed that it needs to be removed. Got denied by the insurance the first time, the surgeon did peer to peer and it was approved on 11/1/17. I had my surgery on 11/21/17. Well, on Monday 12/11/17, I got 3 bills from the hospital, surgeon and anesthesia, totaled $27,000. I call BCBS and they said it was not medicall necessary. I told them, I got the pre approved letter from them and the doctor office called and confirmed that they did approved it. He said he saw in my file and now is investigating about this issues. I called my doctor office today and they have not heard from BCBS about it. The doctor office did say that I am the 4th person so far that this is happening to. The other 3 is fighting with the insurance and that she is preparing all the paperwork for them.

Has this ever happened to anyone? Can you please advice?

When I get pre-approval from BCBS it means that they agree that the surgery is needed, but at the bottom of the letter it will say that they do not guarantee that they will pay for it.

Call your surgeon's office and talk to them about the appeal that they can do to get this paid. Based on what issues you were having after having the band filled again, it does meet medical necessity. However, your surgeon may not have submitted any preop test such as EGD, barium swallow or other diagnostic tests to support this and it is just a matter of the insurance carrier having those reports in hand, so they can pay the claim.

I know this is frustrating, but you do have an appeal process for this as well, so work closely with the surgeon!

Good luck!