Insurance denied

Heard back from my dr office and they denied band removal and vsg stating they have a one wls lifetime clause. ..don't know what to do. ..get another insurance or medical loan....can I fight it dr is doing an appeal peer to peer with the director. ..so sad right now any advice would be greatly appreciated

Which insurance do you have?  I have BCBS Federal they removed my band but they denied my Sleeve back in 2009.  I did self pay getting the money out of my 4K to pay for the Sleeve.  Now, I'm going to try to get revised again to the RNY.  Sleeve did not work for me, I cannot go with the DS because my BMI is not high enough for BCBS Fed to cover it.  RNY will be better for me because I suffer from severe acid reflux.  

 

Best wishes to you!!!

I have personal choice

Dr. Kashishian' s office said CIGNA REQUIRES a bmi of 50. My bmi is 45 and CIGNA approved a revision for me from a distal rny to the DS. I think every case is different. I would want to do only 1 surgery to last for life.

sorry you are feeling badly....is this something you didn't know?  it would be in your subscriber agreement, so maybe you missed it?  if it is medically necessary they should removed the band.  if you have a one time wls clause, no amount of fighting usually helps, as it is a contract you "sign" when you get the insurance, so it is your responsibility to know what you are buying.  when you read your subscriber agreement did you see that in there?  is it clearly listed under your exclusions?   usually the fall is a time to pick different insurance carriers, do you have another option?  that is not that far away?  when you read the subscriber agreement make sure that is not an exclusion in the new insurance.  wishing you luck in your revision...

If there is a one wls lifetime limit clause and you have a choice to enroll in another plan then I would do that. My RNY was about 20,000 to 30,000

 

Ive honestly not seen anyone be able to reverse the one wls lifetime clause.

 

 

Tamara

I did!

I had the one wls surgery policy added to my insurance plan.  I was able to fight and get the band removed as medical necessity.  Than I fought that the band was removed as a medical necessity and and I had proven a medical need for the band in the first place.  I did a verbal appeal and was allowed to go thru the whole process and was denied ever step and had to call again and get approved to move on to the next step.

I made it thru and was sleeved 1/22/13!

Would they at least cover the removal if medically necessary?  I think I would fight for the removal and then do a medical loan for the revision.  Just my 2 cents.  Good luck!

 

thats what i was going to do but i was told they didn't want to cover the removal bc that was a second surgery and the vsg would be a third

So sorry to hear that.  Hang in there!