Denied for revision to DS

I am wondering if anyone can help me. I have the lapband and was denied for a revision to DS because the insurance says I was non-compliant with the band. Does anyone know what they mean by this? Could it be because I didn't lose weight with band? Do you know if it is possible to successfuly appeal this issue?

Thanks for any help.

Ann-Marie

I am waiting on insurance approval (Aetna PPO) for a revision from band to bypass.  Reading my insurance company policy on revisions it says that it will cover a revision from band to bypass if the person was compliant with the band and has a BMI over 40 which is needed for any WLS.  I am assuming your BMI is over 40.  I would call the insurance company and ask them for an explanation.  I would definitely not give up.  Some insurance companies deny you just hoping you will go away.   Are you working with a hospital or bariatric center?  They should be able to help you appeal this denial.

Hi, thanks for replying. I am working with June at Dr. Greenbaum's office. June told me my insurance left a message for her while she was out of the office saying they denied my revision for non-compliance with the band. She said that's all the message said and that they should send a letter. I am trying to figure out what they mean by non-complaint, like I guess what they consider compliant and what is non-compliant. I definately will not give up!! I want this revision so badly.

Hi Ann-Marie-
Don't give up - there are few levels of appeals with most insurance companies. You can submit medical records from your surgeons office documenting compliance. If you show that you completed all your scheduled appointments, show a food and exercise diary, and your physicians notes then they may overturn the appeal. The last level of appeal for most insurance companies is what's called a peer to peer. This is when your surgeon speaks one on one with the medical director from your insurance company that is making the decision on your case. Your surgeon can plead for you that you were compliant, but that the band was not the appropraite surgery for you, etc...they will know what the best thing to say is, not me. I've seen the peer to peer be very effective in many cases. Good luck and hang in there! Billie

I suggest calling your insurance company and asking what it means.  "Non-compliant," in medical terms, generally means a patient didn't do what the doctor told them to do.  It would suggest you didn't follow the diet you got from your doctor or dietician or that you didn't keep appointments for fills or something like that.  If that is what they are saying, you can appeal that and provide documentation that you did those things.  Things like copies of any food logs you kept, records from meetings with your dietician where you discussed your diet, records showing when you got fills, etc.

If they are calling you non-compliant just because you didn't lose weight, well, if you did everything you were supposed to do and still didn't lose weight, that's not your fault.  And duh, the fact that you didn't lose weight is why you need the revision.  If they are saying the fact that you didn't lose weight means you were non-compliant, I would suggest appealing and providing them with the same documentation mentioned above to show that you were in fact compliant but the band just didn't work for you.

Kelly

Where would they get info that you were non compliant with the band? If it is a matter of not following the diet, not exercising, not obtaining band fills, not keeping appts, where would they get that info?

If it is a matter of not losing weight, why would they offer the option of revision surgery?

So many questions. ;o)

You should be getting the denial in the mail, have you received that yet? When you do if you post the wording we can help further.

There is a person here that was denied a revision because she really was not compliant with the band. She did not go for fills, did not keep appts, etc. Last I recall they were still denying her after appeals.

I haven't gotten the official denial letter from the insurance, but I am guessing they are saying I was non-compliant because I do have gaps in my visits to my doctor. I guess I didn't see the point in going when I was not losing weight and did not need a fill and I had to  pay out of pocket for these visits and honestly. My mistake, now it's bitting me in the butt.

How would they know you went or not for these follow up visits?

I assume the records were submitted to my insurance company by the DS surgeon's office with my paperwork to get the revision approval. I'm not sure. I am waiting for a call back from Dr. Greenbaum's office to find out more information. If I don't get a call back today I will call tomorrow and leave another message.