Denied...

I had everything approved; psych eval, PCP, surgeon, upper GI doc. I am the perfect candidate for this surgery.

I was denied because I have had two (self pay) lap bands before this surgery - both removed because of slip - last one removed in 2013. The insurance said that they denied me because I didn't lose 50% of my weight with the previous surgeries. Ummm.. how do you know? There was nothing on any of the paperwork that was submitted that had anything about my previous weight(s). My surgeon's office put that I have had 2 lap bands because they had to - but there was NOTHING about my weight. I WAS successful - I got to goal both times before the slip. So, not only are they making an assumption about something with no data, they made the WRONG assumption.

So, now what? My case manager is going to call today and ask those questions (I was denied via voicemail) - but what are the odds of it being overturned? I mean - they are wrong. Flat. Out. Wrong. Do I have any recourse?

I understand that most of the insurance case manager nurses aren't gastric experts, but seriously? Even if I didn't make goal the first two times - the band was REMOVED twice. How can you gauge the success of something that was removed?

I am prepared to fight this decision because it is the WRONG one. Has anyone ever fought the insurance company? What did you encounter?

Thanks for the support :-)

I have seen tons of these decisions overturned. It happens a lot. Do your dye diligence, but don't freak out.

There is always an appeals process, and it varies by local laws. Hopefully, you are in a larger surgical group that has specialized insurance people that handle these things for a living.

Stay on top of it. Make your appeal. If it gets denied again, it will ultimately go to a peer to peer review. Your surgeon should win easily.

Lots of folj s are on the fence about having surgery at all. If an insurance company can save a pile of money by getting some people to give up by issuing an initial denial, it's money in their picket.

Thank you. This makes me feel much more like I have some control and recourse with this. I was feeling so discouraged - but now that you mention that peer to peer review - I do remember my case manager saying something about that. I will work on being patient and not freaking out :-) Thank you for your input. I really do appreciate you taking the time - this is what I needed to hear.

You were right :-) They did the peer to peer and within an hour, I was approved.

Thanks so much for responding. I kept playing your words in my head as I was going through this process. You seem to always offer such great advice to everyone - and I want you to know, it DOES make a difference. Thank you!

Yes don?t freak out. Hopefully whomever calls from the surgeon?s office can point them to the fact that it was never even addressed.

Good Luck

I do have a case manager where this is what she does for a living. I need to trust that she'll be my advocate. Trust is hard! :-) Thank you so much for taking time to respond :-) I do love this community.

It sounds like you have someone to work through this process with you which is awesome. Try and stay positive and keep us updated.

Thank you! I keep watching the clock - it's 8:52 AM - she should have this fixed by now! :-) LOL!

Patience is NOT my strong point. I am glad at least it wasn't Friday when I found this out!

I'm sorry you are dealing with this Sheila, but like the others have said we do see it happen every once in awhile. It just means it may take a little longer. Try and remember that every single day is a day closer to getting it resolved.

Having said that, I personally would have lost my sh*t. So I completely get it.

You'll be over the hump soon. Please keep us posted.

You crack me up! I TOTALLY lost my sh*t. In the middle of making dinner I went on a very dramatic "I hate food and what's it's done to me" internal rant and ugly cry :-)