Insurance denied me

I was scheduled for a revision on 12/14/09.  I was denied today.  I am so upset and frustrated.  I will appeal but it was so close to my date.  I had my daycare arranged, my office had hired a temp who I will still be training tomorrow.  I have worked a ton of overtime to ensure I had all the time off I needed and I have traveled 2 hours one way to my appointments every time.

My insurance knew I was seeking revision surgery they found the surgical group for me and I asked repeatedly if it is something that is covered.  They told us I do not meet the criteria.  I do not have a fitula, my original bypass is intct and I did not lose 25% of my weight with the first surgey (I lost 42% did the math today so apparently they have missed something in my records).  In my opinion and I am obviously not a dr. the original bypass is not intact if the stoma and pouch are large, correct??

I just cannot believe they waited so long.......how many dr. appt's up to this point have they covered, labs, the EKG and now they deny.

Any suggestions on how to convince them in the appeal.  I have Capital District Physicians Health Plan in upstate NY.  I pay 215.00 bi weekly in premiums I am so disgusted I have so little say here it's not like insurance is free.  They don't cover weight loss drugs, now the surgery and I work for the federal government the peopke that are doing all of the studies on how bad obesity is!

Thanks for any input.

I hate the appeal process... but you are gonna haveta do it!

Get your data together to show that you have met the criteria, along with all the research that proves that "intact"  is not the correct definition for your situation.

Have you had an EGD?  That report might help.  That is what finally did it for my insurance company when I was requesting a revision from the band to DS.  It showed my slip/hernia/gerd damage.

Wish you luck!

Make sure your surgeon does a peer-to-peer review.  It might be as simple as the insurance company missing that part of your records.

My insurance denied me after being reassured I would be approved with no problems. After they denied me my surgeon personally called the medical director at my insurance company(Aetna) and explained my situation. My denial was overturned 2 days later and I am having my surgery on the 17th.. My surgeon even went so far as to push other patients back so I could have mine on the 17th due to only time I can do it while on christmas break.

Talk to your surgeon!! If anyone can get it overturned without appeal or delayed time he can!

Good luck!!

My surgeon did speak tot he medical director and asked for reconsideration but the denial was upheld.  I am gathering some more paperwork and he is going to ask for reconsideration again.  He tells me not to give up and he will keep trying with me. Thanks for taking the time to let me know and GODD LUCK!

What kind of revision are you having?

from RNY to Sleeve

You have gooten some very good replies here, keep your chin UP!!!!!!


-Jamie

I feel your pain.  Even with my fistula, my insurance denied my revision.  I am in the appeals process right now.  Stupid insurance.  It's a love hate relationship.

Your story is exactly like mine right up to being denied the day before surgery, paying for tests, scheduling days off etc.

There are people on this website who have successfully appealed their own denials and this is an option for you too. I, however, was too darned depressed and defeated by the Aetna run around (and scared too). I contacted ObesityLaw.com and have had a great experience with them. It took two weeks from the day they submitted my second level appeal for them to get my denial overturned. I paid a $600 retainer and it was worth every single penny. But... don't let the money stop you if you don't have that much right now (they will work with you). If you need this type of help just call them or email them, they will be frank with you about whether or not they think they can help. When I read the ObesityLaw 'Appeal letter I finally understood why lawyers earn their keep. They wrote a very powerful and cogent argument for the life-saving procedure I had requested.

As far as I understand it... it doesn't matter whether or not they cover weight loss drugs. If they state that they cover bariatric proceedures they have to approve your claim. In addition, bariatric surgery is recommended for people with comorbidities like sleep apnea and diabetes regardless of the potential for weight loss... it's not a weight issue... it's a life and death issue and medically necessary.

I feel for you, knowing what I went through and all the frustration with insurance company jerks. Whatever you decide to do, don't give up, keep your chin up and fight fight fight.  Take care - K