Info Wanted for Lap Band Appeal

My insurance denied my lap band as "investigational". My union provides an attorney to appeal it. Which is great! However, I really feel I need to give him information on lap bands. He's done 2 RNY appeals so far -- lost one and won one. My hearing will be within the next 3 weeks. SO ... I would love anything anyone can suggest to ****ducate my lawyer and (2) convince the insurance company that it is NOT investigational. Someone had posted everything he/she used to appeal, but I can't find it now. I have thought of hiring a WLS lawyer to work with my lawyer, but don't know if they'd do that. I'm open for any suggestions! THANKS Donna C

Inamed offers help to people getting appeals. They can give your attorney the documents he needs for a case. I think the guy in charge is Don Mills. Check out the web site to be sure. Also there are sample appeal letters and data on the yahoo group "BandstersInsurance". Good Luck, cathy

Thanks, Cathy. Your info is greatly appreciated! I will check the sites out and give Inamed a call. Donna

Donna, I also had this denial, and I provided enough information that they changed their tune and are now denying it for "medical necessity" instead, so I assume I got through to them. I used a copy of the FDA approval from 2001 (available on the Bandsters Insurance in Yahoo, I think) and found a lot of studies on the lap band. The Inamed paper for BCBS (not the Hayes report so much) about the lap band is also very good, I think it is also at the Yahoo site. Another thing that I think is very good to point out to show the medical consensus on lap band is a recent (Oct 13, 2004) article in the Journal of the American Medical Association (JAMA) that summarizes 136 studies of bariatric surgery. There is a section near the beginning where they are discussing how they chose the studies to review. It specifically states there that they excluded studies on balloon WLS surgeries because they are experimental. That statement says to me that the AMA, which is the foremost medical association, does NOT consider lap band experimental, or they would have also excluded the studies on it. Hope this helps. If you want me to mail you copies of the research I did, I would be happy to, if you can provide an address, or somewhere to reach you online to get that. Thanks and good luck! Judy

Judy, Thank you for the info. I will definitely look these studies up. My denial listed specific criteria to be met in order to not be considered "experimental", and I think the AMA article in particular might help meet a few requirements. If you don't mind, I would love for you to email copies of your research. My email is [email protected]. My lawyer has done a lot of insurance appeals, but doesn't really know anything about lap bands. I really appreciate your help. How is your appeal going now? How can they change the reason after your appeal?? I wish you luck! Donna