Final Denial of my Final Appeal

Friday night I recieved a letter in the mail from my employer.  They have denied me based on the fact that the procedure is considered experimental and investigational in nature.   "The reason for this denial is that Lap-Band system bariatric surgery has been determined to be experimental/investigational." It goes on to say that the decision exhausts the claims procedure available to me under the plan and that I have the right under ERISA to file a civil action.  I have 180 days to do that.   I have 2 questions.  The first is....What does a civil action entail and will I need to spend buku $$ out of pocket to pursue the civil action The second is....What does the sentance below mean?????  (The letter started with this sentance and it makes no sense to me since my employer is self-funded and determines what is covered and what is not and other "administrators" that my employers use DO provide a benefit for Lap-Band and don't consider it experimental/investigational) "According to the Employees' Group Benefits Plan of Alcoa Inc. (the "plan) the claims adminstrator determines if a service is medically necessary for diagnosis or treatment of a pregnancy, accidental injury, or illness.  Medical necessity is determined using standards approved by the clams administratior's personnel" Does this statement mean that Alcoa doesn't have to budge on anything because it lays all blame on BC/BS Highmark?  Is Alcoa saying, according to how the plan is written, the administrator (Highmark) determines if a service is medically necessary........not Alcoa.....and furthermore....Alcoa defers to Highmark guidelines when an appeal is made? I'm now truly at the end of my rope. I've always said that I would never give RNY a second glance and it would be my absolutely last alternative but I think I might have to give it some healthy consideration.  I've lost over 18 lbs on my own in the past 8 months and still have a hard time doing so many things.  I'm 40 years old...I cannot continue on this way or I'm going to end up like all of my family, dead or dying of heart failure. I could just sit here and cry.... Thanks for listening. Gina B.

Most BCBS in many states still consider Lap-Band to be investigational.  That is in my policy with BCBS of Alabama.  I initially wanted Lap-Band, but after doing extensive research, I decided that RNY would be a better alternative for me.  I still had to follow BCBS guidelines for 6 month supervised diet and such, but I had absolutely no problems getting approved for RNY.   I'm not saying that Lap-Band doesn't work for some people, but I had a BMI over 50 and I didn't want to take the chance that it wouldn't work for me, as my policy has a one-time per lifetime WLS clause barring physical complications.  I go to a mixed support group at my surgeon's office with both RNY and Lap-Band patients and I must say that the RNY patients seem to have less daily vomiting, GERD and food intolerances (with food texture and geting stuck as opposed to sugar and such, which would make us sick where it would not with a Lap-Band patient).  I've personally met 4 people already that had to have their bands removed due to slippage, erosion or intractable GERD and none of them lost more that about 30-40 pounds.  That's not to say there are sucessful banders out there, because their are.  You might try the Lap-Band board here and see if anyone there has been successful getting BCBS to pay for their surgery. As to the medical necessity, it really doesn't matter, as they consider the procedure investigational and will not pay for it even if  you meet the criteria for medical necessity.  If your employer uses a company other than BCBS  to administer its plan, then your only alternative is to have the other company administer your claim...how that works, I do not know.   I have to say that I could not be happier after my RNY.  I am about 5 weeks post-op and have had no problems to speak of.  I know you probably researched your options thoroughly, but you might want to give a little more thought to RNY if you have no way around BCBS.  Good luck with everything.

Does your insurance cover RNY???  The lapband wasn't covered by my insurance, so I had GB and have never regretted it!   Annette

Gina, I was also denied initially and both of my appeals were denied. I appealed to NYS Dept of Insurance and they reversed the denial. Is that an option for you? I did not look at what state you are in, check and see if that is an option, there might be a fee, through my insurance there was no fee. Hopefully this will be an option. Good luck.