Insurance Peer-to-Peer Denial... Any Hope?

Hi All,

My doctor just had a Peer-to-Peer interview with the insurance doctor and the insurance as said there is no way they will consider VSG for me.  I currently have a slipped band that needs to come out (so I have to have surgery anyway), but insurance won't budge.  They said they will consider a Bypass, but not the sleeve.

Is there anything I can do beyond a peer-to-peer?  How many times can I appeal?  My doctor's office feels peer-to-peer is the end.

It is so frustrating that some states will cover this and some won't... there are also some doctors who will code differently so patients can have the surgery and others won't... WSL seems to be a very unfair practice.

I will post on the insurance board also.

Thank you in advance for your help.

Donna

 Call up your insurance company and they should be able to tell you how many appeals you have. You need to check with your state to see what your outside appeals options may be. Here in CA we can appeal to the Dept of Managed Health Care once we've exhausted all our internal appeals. Maybe you have something like that in your state. You can also contact your insurance commissioner. I would say to just appeal and see what happens, you never know. Post on the VSG board and ask if anyone has had their denial overturned and if they have a letter or studies you could use. That being said the VSG is considered investigational by most insurance companies still so if you can't get that covered have you looked into getting the duodenal switch (DS)?

Appeal it and if you need help writing the appeal I am here to help   Also you have the right to an external appeal which I will be more than glad to help you with.   Does you policy have WLS and if so do they cover VSG or consider it investivational   PM me I will help the best I can or give advice