DENIAL is not a river in Egypt!!!! (Lap Band)

No, it's not a river.  It's longer, deeper and the waters are much muddier

When I’ve just about lost all hope a tiny ray comes shining through.  Yesterday after noon I received a call from my insurer (Highmark BC/BS). It was a girl telling me that she had my appeal and needed to go over a few things.  I didn’t understand why SHE had my claim because the last appeal I made was to my employer (Alcoa).  She said that Alcoa had contacted her because I had appealed to them in error.  The appeal, at that stage, was supposed to be made to the insurer. 

 

The timeline went like this…..My doctor filed my initial paperwork.  It was denied.  With that denial were instructions on how to appeal to Highmark.  I appealed and was denied again.  This appeal has no instructions on the next step so I called them and was told that I had exhausted my appeals with Highmark and now had to go to my employer.  The proper paperwork was sent to me and I filed an appeal with my employer.  This appeal, as it was explained to me, was IT.  This was my final attempt at trying to get approved. Until yesterday I’d been waiting 2 weeks and still no word but I was told the process could take 60 days.  Then I get this call from Highmark yesterday saying that I was really allowed 2 appeals with Highmark before going to my employer.  I had been given mis-information and she apologized. 

 

We spoke for quite a while and she really listened and took the time to hear me out.  She said that I had a choice of using my 2^nd appeal with Highmark or going straight to my employer.  However, if I waived the 2^nd appeal and my employer denied me, I couldn’t go back to Highmark. I expressed to her that I didn’t see what good it would do to appeal to Highmark again.  Highmark denied the doctor once and me once and both times for the same “experimental/investigational” reasons.  She encouraged me to try again.  She told me that the first level of appeal went to the medical review board and this current appeal would be seen by an appeals committee.  She said that they review appeals in a very different way and look at things that the medical review board wouldn’t. She said that at least if I was denied again by Highmark I would still have another chance up my sleeve with my employer.  She really encouraged me not to give up and to use this 2^nd appeal.  It was like being given a second chance as spinning a wheel to win a million dollars.  She even gave me her direct number and told me to call any time.  She is going to expedite my appeal and tell them it’s a high priority appeal.  She really wants to see this approved by the end of the year because I’ve met all my deductibles and doesn’t want it sitting on some ones desk.

 

So, there it is in a nutshell.  I’m really trying not to get my hopes up too much but I just have this feeling that this time it’s going to be approved.  I have to say it was just nice to finally speak to someone from my insurer that was sweet, kind, considerate and seemed genuinely interested in helping me.

 

All of you out there who are waiting and hoping, I’m right there with you. I know how depressing and frustrating it can be. Please try not to loose hope.  You never know what the next phone call might bring.

Take care everyone, Gina B.

Hi, I have Highmark BCBS...can I have her number....see my post above....

Good luck with the appeal.  Its nice that you have someone on your side at the insurance company. Wondering if you've forwarded the medical journal reports that state LapBand is NOT experimental and has in fact been approved by the FDA?  You might want to add that to your file just as added weight on your side.   Good luck, Pam