EXPERMIMENTAL/INVESTIGATIONAL LANGUAGE

I just want to throw this out there and see what everyone thinks. For those of you who have been denied for the reason that your insurance company considers the band experimental and investigational in nature..... Do you notice how difficult this is to beat?  We all know it's not REALLY  "experimental & investigational" but then the insurance company adds this wonderful little spin on the entire thing by saying something to the effect of: This consider an invervention 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.

Only 1 of the above needs to be "accurate" and it only has to be accurate in THEIR eyes.   My insurance company KNOWS the band is FDA approved.  They know the band improves health outcomes and that the band is applicable outside the research setting.  Their main contention is bullets 2 & 3.  It is because of this that they consider the band to be investigational/experimental.   What really gets me is that they then say that there isn't enough data to prove the effectiveness of the band over RNY. What is enough?  I've asked them and they don't even know!!!! Sorry, just had to vent and just put this down in writting.  Maybe if I do it will stop bugging me so much at the stupidity and close-mindedness of my insurance company. If any of you have won the ulitmate battle after being denied with this specific language.  PLEASE TELL ME YOUR SECRET!!!! Thanks, Gina

I can't help you with the whys and wherefores, but I can tell you that I have BCBS of Alabama and they do not approve Lap Band either.  The policy used to state the reason was that it was experimental and investigational.  As of last year, they crossed out that language in the policy and now simply state it is not covered...they're not saying its investigational anymore, but they're not covering it either.  I know that doesn't help you, but is interesting to me.  Possibly they changed the language due to someone forcing them to cover it because it is obviously not investigational anymore?

Angela: I've heard that BCBS Alabama is as hard of a nut to crack as my BCBS is (mine is Highmark BCBS)  I think the experimental language was an issue in the past with Highmark also because now they put all those bulleted items in there.  When I called the rep the conversation went something like this: me:  so you are saying that even if one of these bullets in applicable, then it's considered to be exp/investi. them:  Yes me:   Which bulleted items are you denying me on. them:  2 & 3 me:   But I gave you a ton of information in my appeal that showed the the band was as effective as RNY.  I gave you 45 pages of medical studies!!!   them:  They weren't sufficient me:  They weren't sufficient in content or volume? them:  I don't know mam.  They just weren't sufficient me:    How many more studies do you need to have a sufficient amount of data? them:  I don't know mam.   HOW FRUSTRATING IS THAT!!!!!! How did it go with you Angela?  Are you still appealing?  Did you get the surgery somehow? I hope all goes well and that we both get what we deserve in the end. Take care, Gina

I just gave in and decided to go with RNY.  But I know how they are because I initially wanted LapBand.  This is not the only reason I went with RNY, I really think it will be the correct procedure for me, but I also don't think they should deny the band just because it has been around that long in America...its been done in Europe for years.   And they cannot site a reason, but I think something must have got by them in the past for them to change the statment in the policy like that.  Someone must have fought them enough to make them change it, whether the approved the surgery or not...I don't know.  I know how frustrating it is for you though.

well regarding #2 Available scientific evidence does not permit conclusions concerning the effect of the intervention on health outcomes sounds to me like they might be waiting for a few "ten year studies" to come out... the LAP-Band was only approved, what, like 5 or 6 years ago.  It's still a baby in the eyes of medicine. regarding #3 The intervention is not proven to be as safe or effective in achieving an outcome equal to or exceeding the outcome of alternative therapies this one may be tough to EVER win with. Yes, the LAP-Band is one of the safer (if not the safest) procedure, but at the same time, it also has the lowest statistics of percentage of excess weight loss and (so far) the re-gain rate (I refuse to say "failure rate") is higher than other procedures.  these two combined, when solely viewed under the context of the bold sentence above, pretty much eliminate LAP-Band from your insurance company's approved procedures until such time that they rephrase (or completely change) the policy does that make it a BAD procedure? not at all if YOU and YOUR DOCTOR feel it would be best for you.... it's only bad (or at least inferior) in the eyes of your insurance company because all they look at is the hard statistics.  This post is not in the least intended to be a "procedure bashing"... just trying to offer an unbiased thought. I wish you the best of luck with this situation... perhaps you'll luck out under appeal or the peer review process.

Gina, Here's an approach that might influence your insurance company: In Feb. 2006, Medicare released its f"Decision Memo for Bariatric Surgery for the Treatment of Morbid Obesity". Their conclusion? They approved coverage of the band for Medicare recipients, stating "The Centers for Medicare & Medicaid Services (CMS) has determined that the evidence is adequate to conclude that...laparoscopic adjustable gastric banding (LAGB)...[is] reasonable and necessary for Medicare benficiaries who have a body-mass index (BMI >35, have at least one co-morbidity related to obesity, and have been previously unsuccessful with medical treatment for obesity." I've read the whole 34-page statement, which is outstandingly reasoned and backed up by thorough research. It included a discussion of  the extemsove evidence they reviewed, whi*****luded technology assessments, professional society positions, and expert opinion. I would send your insurance co. a letter requesting reevaluation of their coverage for WLS. Point out that the national Centers for Medicare and Medicaid Services recently changed their position on coverage. Include a complete copy of the statement, which you can find at http//:obesityhelp.com/forums/insurance/ode,pcontent/cmsID,8238/.imply subtly that they're behind the times on this issue. If you can get it, include a list of the major insurance companies that DO coverage WLS. Finally, check the blue panel on this site for tips on what to do if denied and helpful articles. Keep us updated on your efforts. Even if they won't bend now, your effort will put them on notice and may help you or others in the future.

I wonder if some of the reluctance on the part of some insurance companies to cover the Lap Band might have to do with the ongoing cost of post-op office visits for port maintenance, fills, etc. Maybe it's more a long term expense issue than any valid or justified medical reason...