Better after a good cry

I've had all my required pre-op testing and sent all my required documentation in to be approved for WLS.  I have decided that VSG is the best option for me.  I will consider the LapBand but really don't want to do that.  I am not a candidate for RNY and wouldn't have it if I was

I knew going in that my insurance excluded VSG but approved the band or RNY.  I spoke to the insurance person at my surgeon's office today about approval.  I wanted them to submit for approval for the VSG so that we could get a formal denial and start the appeal process.

The insurance person at the surgeon's office said they won't do that for excluded services.  My only option, according to her, is self pay.

I am so frustrated. I don't think what she is telling me is right.   I work with our health plan at work (I am on my husband's ins) and I know we have had members appeal our insurance plan for WLS even though that plan excludes all WLS.  Both my husband's insurance and the insurance at work are self insured plans which gives them alot more freedom when it comes to appeals than with a fully insured plan. 

I have been advised by my surgeon's office to let them handle the insurance company.  I contacted the insurance company myself once before about this and it caused some confusion.

I want to appeal the exclusion but am not sure if it will cause me to be denied for any surgery.  I have a copy of the appeal process thru our insurance and need to go back and read it again.

In the meantime, my husband is talking to HR at his work to see who makes decisions about plan changes.  The TPA only administers the plan.  I need to go to the decision makers to try and convice them to change the plan to accept VSG for this upcoming plan year (beginning 1/1/11).  I don't know what else to do.  I am at a loss.

Self pay is an option but one that would put a real hardship on my family.  It's hard to explain to them why I won't just settle for the band.

Going to Mexico scares me to death and my husband would NEVER go for it.

Anyone have any suggestions?

I would talk with the surgeon directly about what you want to do, and get him/her to put pressure on the insurance person to submit the paperwork anyway. I would bet the surgeon would rather try and have the possibility of getting paid for the surgery than to lose you to another surgeon.

Good luck!

Tonia