Peer-to Peer Dr. Insurance appeal success rates?

Does anyone have any statistics for how often these are successful? After a first denial your doctor calls the insurance company Dr and essentially tries to get them to overturn the denial. Their job is to save the company money so I am not confident. I need revision from lap band to RNY. The denied the request for conversion before my endoscopy which found my band is twisted and needs to come out, plus I have some GERD as a result of the vomitting from the band for the past two years.

Insurance co is saying I was no compliant because I didn't lose enough weight. I lost 30lbs and maintained that. I never could lose more then 10-12 with out regaining before. Another complication is that I stopped seeing my first doc because he would yell and degrade me when I didn't lose ast enough.

So new doc is going to share all this, but I am still too worried about it and thought I'd see what kind of information folks might have about this process.

Thanks

I'm sorry to hear that you are going through this. "stopped seeing my first doc because he would yell and degrade me when I didn't lose ast enough."  What the hell is that??  You deserve a doctor who will care about you and support you. Anyway...I have read on these forums that many people have been successful with the peer to peer reveiw. Sending good luck vibes your way!!

Thanks so much for your kinds words of support Tiffinay. The update is my doctor has scheduled three phone appointments where the insurance company doctor is supposed to call  my doc and eh hasn't done that. I am freally frustrated by this. I think they are stonewalling. My doc is going to tell them about the treatment from my former doctor. They know nothing about it. We are hoping that once they know they wil change their minds. I do have another insurance company I can change to in December if I can't get anywhere with this one.  It is very frustrating.

Andrea

Hi, I'm in the same situation... the medical board director has not returned my surgeon's phone call... he is trying again today between surgeries.  I'm sorry I don't know the overturn statistics.

My frustration is so high inside I feel like a wreck.  My surgeon's office staff have been wonderful, but they can't make the insurance call back.

Mine also is a revision from Lap Band to RNY... but there is 25 months inbetweeen.  When they removed the band, there were so many adhesions, plus a fistula had formed, and organs were so swollen, that there was no way he could do the RNY while he was inside.  Things had to heal first.  Now, everything is healed... and I was denied because I didn't meet the criteria for an original surgery... I had been successful with lap band... lost 120#... then everything went to hell in a hand basket in a hurry.

Let me know if what you find out, please!

Hi Kathleen, I am so sorry to hear of your troubles. I am a bit worried about what the surgeon might find when he goes in. He does know the band has turned from my tests. I went through what you are going through with the phone calls. My insurance company is CIGNA. It took twelve weeks for them to finally connect. Mostly because the insurance company was doing a he said she said game. Of course, I believed my surgeon. The insurance company would say they called at the appointed time and he wasn't available. Of course he was. Finally after I got the insurance representative for my plan to call CIGNA a few times, it finally worked.

Stay tough and advocate for yourself.I was very depressed during this time, but things turned around when it was finally approved. Have you tried getting the insurance rep for your employer or whoever your plan is through to call your insurance company and pressure them?

Andrea

Hi Andrea,
I'm retired Air Force and have a huge group plan called Tricare West or TriWest... I don't have anyone there as a representative... I am starting to pull things together for the appeal, just in case.

Yes, I, too, have been battling depression because of the frustration of hearing anything or trying to find the information on how to appeal... they truly don't make it easy.

I do know that when I do appeal they have a short window of time to get back to me, so that is good.

And I found I have another option, should I want to got that way, and that as Vet I am entitled to VA care... it is more expensive tho.

I do believe the peer to peer call will be successful, I just like to plan for contingencies.  I believe we should always, whenever possible, have a back up plan.

And I do know that persistence will pay off!

Please let me know what happens with you and I'll let you know on my end.

Well first thanks for your service. Good for you for building for your appeal. Keep calling your insurance company.Don't let them off the hook!

Thanks, I won't!

Good for you!

Hi Andrea, I got my verbal approval today!  Should have the written one in the next day or 2, then they will schedule the surgery!!!