Question about ins. laws...

I just got my approval for lapband today (I'm so excited!!)..... BUT, the only way I can have it done is if my surgeon can "work me in" by 12/31/04. My ins. co. told the doctors office that it absolutely had to be done by then because they will stop covering bariatric surgery as of 1/1/05. I've been working on getting approval since July. This approval came after appeal. My question is....can they deny me if the surgeon can't work me in by 12/31? They have been dragging their feet on the approval and now I don't know if there is time to get it done. The surgeon's schedule is very tight between now and then...so, he may have to turn me down. What do you think? Can they deny me if its not done by then? Thanks for your opinions !!

Hi, I wish I had an answer to this one as well. I also have an insurance company that has been dragging its feet. I did not find out about the new exclusion until the employer information came out in September, when I was already scheduled for the doctor's seminar, and I got to work immediately, with the doctor's help, to get everything to the insurance, although there was a ten day delay after the doctor's letter was written because his assistant was out of the office and no one mailed it. First, they denied lap band as "experimental" - I sent them a ton of information showing otherwise, they denied it again for the same reason on appeal, and I overnighted a request for the next level of appeal Friday, telling them I was also going to contact the Department of Insurance. They called me yesterday and said my claim could not be considered until I submitted a three month doctor-supervised diet within the past six months, a psychological exam (which I was earlier told I could not go ahead and get without approval, now they say I cannot be approved without it), and a pulmonologist exam (I have sleep apnea which is treated by a CPAP machine). It looks like they have abandoned the experimental defense and are trying to delay in another way, but my doctor's office has said there wouldn't be any way to get it in now anyway. I plan to get my complaint to the insurance dept today, asserting that they have deliberately tried to run out the time because of the new exclusion and also because they won't be one of our carriers next year. I am asking that they be required to cover the surgery under the old plan in the new year. In our state, it looks like I may be able to claim they have not provided timely response on their determinations, because I think they should be held to the timeframes under our utilization review laws rather than claims appeal rules, as there has not yet been any actual claim, just a pre-determination. I will let you know how that goes. My fight is also complicated by the fact that yesterday, when I called the doctor's office again, the assistant told me that they won't be taking the new insurance company that I chose, as of November (we had to pick a plan in October, and they were on the provider list then), so I would have to be out of network even if I could get through the exclusion, so that gives me even more incentive to follow through on this - what have I got to lose? I was a little upset with this assistant, because she was pretty much telling me I should give up and self-pay, but that's not my nature, and I just cannot have this done without insurance. I suggest if you cannot get the surgery before the end of the year, you might want to send a formal request for after the first of the year, and follow up with your Department of Insurance if you have to. Let me know if you find they have to cover - that would help me out. Good luck to you!

Unfortunately, they can deny you if the Dr. can not "work you in". My surgeon had to work me in as well. I got pretty lucky and got a 12/10 date in one week of my approval. The surgeon can make it happen. Stress to him/her that this will not happen if he/she does not "work you in" by the end of the year. They will do it if they are caring enough about your health. Let me know how things turn out for you Krissi

They can deny you, but you can appeal and win. Who needs the aggravation though? I agree that you should work on your surgeon to get a date.

Unfortunately, I have no choice but to appeal and try to get them to do it in the new year, as I still don't have approval (2nd appeal hearing scheduled for 12/22) and my doctor's office has already said there is no way to get it in this year. If I win my appeal, will I be able to make them do it in the new year? I am in a bad situation because 1)the company is not a carrier for our plan in the new year; and 2)my doctor will be out of network for the new carrier (which I just found out - he was on the plan when we had to choose back in October). Also, if I am not able to attend the hearing (2 hours away, 3 days before XMas, meetings scheduled at work), will that hurt my cause greatly? The rep from the company said she would present my case if I was not there, but that doesn't sound terribly promising. Can I ask them to reschedule, and if I do, will that hurt my case as well?