Insurance Issue After Band

I had my LapBand done in 2007. At the time I had BCBS Fed. and the services were paid for. As of this past year I divorced and have a new insurance that has a exclusion from any Bariatric Services. The insurance I have is PAI thru Preferred Blue. I am having a lot of pain with my band and need it removed. I called PAI and was told they would not pay to have it removed or for any of my office visits for anything related to it. Has anyone been in this situation? Have you got your insurance to pay by appealing? I am suffering and I'm afraid to even go to my doctors in fear of going into debt and not being able to pay for it. Any advice? I soooo appreciate it!

Teresa

Sorry that your going through this. I personally Don't have any experience with Denials but perhaps you can find out more on the Failed lap band boards the LINK is in my signature line.

What type of pain are you experiencing? How long has it been occurring? Has it been severe enough to cause you to go to the ER? Feel free to contact me send me an IM if necessary. I'll  however I can .

I would encourage you to follow through with the appeals process but do be aware, they have the right to exclude anything WLS related.

To appeal what you need to do is look at the wording carefully on your policy and look at the wording on the denial.  Compare the two.  Are they failing to meet the terms of their own policy? If so, you appeal based on that.  If they are  meeting the terms of their policy the best you can do is complete the appeals process anyway and AFTER you have exhausted your appeals have your doctor do a peer to peer with your ins co and just ask them out of the goodness of their hearts if they would pay for it anyway.  If they decline, they have the right.  WLS is a seperate rider on the policy, if they are not paid premiums for anything WLS related, they have no reason to pay for the procedures.

I suspect you will soon be self pay.  :(

My cousin's insurance denied her band removal, but it had to come out. Her doctor billed her insurance for "exploratory surgery" to resolve the gastro issues she was having (which we all knew were from her severely slipped band), and said that he removed it during the surgery when he realized it was slipped. It may not work for everyone, but she and her doctor got around the bariatric exclusion that way. I don't know much about it, but I would think that you could appeal your insurance for medical necessity if you can prove that the band slipped, eroded, or caused some kind of damage. 

I'm really sorry this is happening. 

You probably need to get the band out sooner rather than later, no matter what.  This is happening with alarming frequency... insurance companies saying, "Too bad, so sad."  Having been damaged badly by a band, I'd get it out and worry about paying for it later, personally.  The band causes a lot of damage... the longer it stays in, the worse it gets. But I'm SO very sorry you're going through it. I hope you can somehow work with your surgeon to convince the insurance company that it's a medical necessity.

Good luck. Take care.

I have the same type exclusion and I've called the ins. a couple of different times and was told the same as you. Fortunatly I had mine emptied and haven't had any more problems, so far. Have you tried getting a total unfill? It might help and couldn't hurt at least it's cheaper than surgery. Good luck you aren't alone that's for sure!

your post doesn't state specifics so here goes....first....every insurance pays for emergency situations and anything that is medically necessary....the problem is you say you are having a lot of pain?   that is not medically necessary reason to remove the band, or revision.  you have to prove the reason to your "pain" is medically necessary, where does the pain come from?  internal damage (band is great for that) or is it the port?  -here come the challenge

first what is the reason for the pain?  do you need it deflated? no biggie (probably not that), what radiological tests have you had done?  barium swallow is pretty good for showing slippage, dilation, motility issues. endoscope would show erosion, manometry (horray I had all of those and then some)  yes as you can see even those with a no bariatric clause would pay for medical necessity issues like this as essentially they are immediately life threatening (erosion) etc...if your radiological tests show no issue, then you havent established medial necessity, if you have not had any tests to prove your case---um forget about it, you have to establish medical necessity....

only you know your body, know your insurance policy well, forget about calling the insurance co, get a copy of your subscriber agreement, this is your contract with your insurance co, you can get this from you HR dept or the insurance co, this is your right, not your benefits summary.  You need to know EXACTLY what they cover, dates, timeframes etc.  read the section on exclusion, medical necessity, how to handle appeals, what is covered, etc.....

I had the band for 8 years, the last 2 years were a living nightmare for me and 3 years after explant I am still dealing with the permanent damages it caused....within 1 days after explant I felt 80% better.....good luck to you...

I would have to disagree with you that every ins pays for emergency situations and anything medically necessary.  They don't.  There are a ton of folks out there that had to have their band removed on an emergency basis, they didn't have WLS benefits, and they are self pay for the entire bill.  A friend of mine is a good example, she had a slip, was severely dehydrated, couldn't eat or drink, couldn't even keep her own saliva down.  She was admitted through ER and had emergency surgery.  The band was cutting off the blood supply to her stomach due to the slip.  She's now self pay for many thousands of dollars in hospital and surgeon bills.

If someone has WLS and they want to remove their band - if they have WLS benefits they do not have to wait for a prior auth to remove the band in an emergency, but for someone with no WLS benefits they are self pay for band removal.

oh my gosh, how awful, I myself didn't have WLS benefits either, was repeatedly told and denied due to a contract exclusion,  once I established medical necessity, (it took level 2 appeal and lots of documentation via radiographic testing, that was the key for the insurance co. in my case)  not only was everything paid for, having a HMO, they approved for me to out of network because there was no one who could take the severity of damage I had locally.  It was an uphill battle though....wishing you the verybest in getting heatlhier....

The insurance company did that because they are nice, not because they had to.  Organ transplants are a medical necessity and if organ transplants are a non covered procedure (and for many this is the case) then medical necessity or not, it's not covered.

Perhaps your doc was friends with the medical director of the ins co, maybe someone made a mistake, maybe the peer review doc has fat kids in need of WLS.  I have no idea. But they did not have to do that.  Great that they did!  But they were not legally required to do that for any reason.