Denied for lap band removal and new surgery - new doctor - attorney involved help

He could have missed it because he only did an Endoscope, which can only show so much from the inside only.  Yeah, my health is CRAP since that last big weight gain. I'm not sure about suing for that. I know it's not listed as a side effect and yet I had it.  There are other instances on the net that talk about people having the same thing.  Thanks for replying.

Yvonne

Wow! You have been put through the ringer haven't you. I don't have BCBS but I do have Tricare... 

I REALLY had to fight hard to get approved. My original surgeon is not in network anymore. I saw one surgeon for 5 years as I gained and he finally agreed to do a distal revision from a RNY. They put in the paperwork eventually, and it was denied. I was so unhappy with the way the surgeons office handled it I found a new surgeon. He is FANTASTIC! It still took a lot of persistence on both their and my to get an approval, but after a long fight.. here I stand 5 weeks post op! 

Personally, I don't think you so much need a lawyer as you do a competent surgeon and his / her office staff to get this surgery done. It sounds like you have a huge amount of verifiable evidence that shows you need this revision. It is now a matter of making the insurance company agree. The first thing I would do is find a new surgeon. Then with all your medical records proving everything you are saying about efforts to lose, diets you have been on, and confirmed medical problems involving the everything, go meet him. 
If possible, in the meantime, I would write a letter to the insurance appeal council. Make it a factual appeal.. ie.. this is what I currently have going on weight wise that impacts me negatively in a physical way. Get letters from every doctor you have seen that you can get to agree that you physically need to have this revision. After you get your factual letter and the letters from the various doctors, search the web for medical publications that study the effects a revision has on your body. What the long term outcome is for a revision are.. What kind of evidence supports a revision... anything like that. Medical publications also related to your various medical issues and weight. 
Gather all of it up, put it in a binder- then mail it to the insurance appeal board. Give them 2 or 3 weeks then start making phone calls.. LOTS of phone calls to the insurance company. Be a royal pain in the ass. If they deny again.. find out the reasons, then counter them with more evidence. If at this point, you still get denied.. then go with a lawyer. But I would suggest a small local lawyer if possible. Big Box Lawyer companies don't necessarily have your best interests up front of their minds. As such, you are a number, an income provider not a human. I would look for someone you can walk into the office of, have them meet you face to face, and then ask for help. 

I hope things start going the other way for you.. I remember all to closely just how frustrating and angering it was to get insurance to say yes.. but I refused to accept no.

I know that this surgeon's office is not used to having to fight so hard to have someone approved. They literally looked like a 'deer in the headlights' when we were talking about it. I have found a new surgeon about 2 hrs away, which is who I wanted to go with originally, but the distance put me off. She's very good at getting insurance approval.  

How long did it end up taking you getting approval after your denial, with the new surgeon I mean. Thanks for taking the time to reply!

Yvonne

For me, 4 days! I got the approval on Wednesday (but i didn't know until I called them) and surgery was scheduled right away for the following Monday.. I am not sure but I think the surgeon had been holding a space to get me in for awhile. Not sure but he is a really in demand surgeon so maybe it was a nice coincidence!

HI, I know this post is three years old, but how did things work out? I have also been denied and have asked Lindstrom to help me if the peer to peer with my doctor doesnt do any good. Did you get your insurance to approve you in the end?

Madss

First with only having an endoscopy that would not show many of the complications of lap band, you need a barium swallow, and I am shocked you didnt have one, that is first thing to do.  if you can't show any functional issues, having the band removed will be an uphill battle to get insurance to pay, since-there is no functional impairment, of which I can't believe, i'm sure you have impairment, especially for 10 years.

2nd the amount of time you have been waiting for Lindstrom is short, and yes you need to tell them exactly what is going one so they can advise you

3rd traveling 2 hours for DS is nothing, many would love to have a DS surgeon only 2 hours away, I am one.

hang in there, keep advocating for yourself, 2 hours is CLOSE, let your attorneys know what is going on....wishing you well in the journey

On 10/10/15, I asked the Lindstrom office to assist me. Kelley is who I spoke with. I've appealed and was denied for the once per lifetime benefit. I had the stomach staple in 1996. What I appreciate about Lindstorm is if they arent able to help they arent going to take your case. Look on the BBB about the company and their mission. Being a divorced mom of 6, the prices are intimidating. But I too was placed on a payment plan and though they cant guarantee a win, Im happy I dont have to deal with my insurance company AND I can honestly say I tried to get help to better my health. Stay positive!

Hi,

I know this post is three years old, but how did things work out? Kelly is going to be helping me with my insurance denial as well. Crossing my fingers.

Madss

Hello,

Unfortunately, I changed insurance about 3 months into the process, so Kelly refunded me most of my money back as a courtesy. I hope things go your way!