State by State Lap-Band® Surgery appeal rights link

sue in ne · 12-27-2008, 10:48 PM

Has anyone run into a denial after approval? I have a letter with an Auth # from the insurance Co. Then today, after surgery, they sent me a note saying it isn't covered ( all the bills from radiology, anesthesiology, and the surgeon )
(9K worth!!)

roxie · 12-28-2008, 05:50 PM

Quote:

Originally Posted by sue in ne

Has anyone run into a denial after approval? I have a letter with an Auth # from the insurance Co. Then today, after surgery, they sent me a note saying it isn't covered ( all the bills from radiology, anesthesiology, and the surgeon )
(9K worth!!)

Sue,
You need to call or write your states Department of Insurance or equal to, to find out their guidelines and regulations for this situation. Be sure to tell them that you have an authorization number, etc., the whole process from beginning to now and don't leave anything out. You should receive an acknowledgement of your appeal and an approximate timeframe for a decision. Good Luck!

sue in ne · 01-01-2009, 10:06 PM

All, Called the Ins Company on Monday- They do not pay the surgeons, etc until the hospital bill comes through and is paid. OK, but in the interim they sent me a note showing the cost of the services was mine- bad business process. The hospital billed and haven't heard , yet.

basketma · 01-08-2009, 08:16 PM

Kaiser So Cal is now approving this surgery but you have to do a song and dance for it. Check it out.. my husband who is an uncontrolled diabetic, hypertension, sleep apnea with cpap intolerance and a knee replacement in HIS ONE LEG could barely get approval- for the bariatric surgery.. I am now hoping for him to get the LAP-BAND® instead, nevertheless me, also 100 lbs overweight but healthy-fergetaboutit. I was on a 12 step and lost 100 lbs, I kept most of them off, but I am still 100 lbs overweight and was starving the whole time I was on that plan. If I had a band I could stick with it. The sad sad part... I work for kaiser. truly disgusting. I now am going to the appeal thanks for the info, I should have remembered it from all the fun I had getting him the knee replacement - when reported, Kaiser suddenly stopped dragging their feet

jtoler · 03-18-2009, 09:40 PM

I can tell you the hospital I work at is a BAriatric center of excellence, it is not a rating given out very often as I understand it...the hospital is in southeast Georgia (Brunswick) SouthEast Georgia Health System the name of the physician group is georgia coast surgical (Medical Weight Loss Georgia :: Georgia Coast Surgical) good luck! I am just beginning the process and am sure I will be fighting AEtna...

roxie · 03-19-2009, 02:53 PM

Quote:

Originally Posted by jtoler

I can tell you the hospital I work at is a BAriatric center of excellence, it is not a rating given out very often as I understand it...the hospital is in southeast Georgia (Brunswick) SouthEast Georgia Health System the name of the physician group is georgia coast surgical (Medical Weight Loss Georgia :: Georgia Coast Surgical) good luck! I am just beginning the process and am sure I will be fighting AEtna...

Hi All,
Your employer determines what your health benefits will be. The health plan only administers the benefits. So if your request for authorization is denied you need to contact your health plan representative, or Human Resources, where you work. Of course if your employer is the health plan then you would appeal to them. Make sense?

monylove · 04-29-2009, 10:25 PM

i am in a horrible position right know and i need som help or advice. I had my surgery in March and was approved and i just received a bill for over 25000.00 from the claims that they will not pay the bill. i went thru medical mutual of ohio got pre registered a week before surgery and was never told that i would be denied. I even recieved a letter from the medical board that it was a medical necessity to have the procedure done. Is there anyone who can help me withe som advice on how to get this paid. there has been people have this procedure done at work last year and not have these problems

luvmy2dogs · 04-30-2009, 09:20 AM

Hi, Why would your surgeon do the surgery without an approval letter. Do they have an approval letter. Check with your surgeon. Mine would not do the surgery at all without some kind of letter saying the insurance co. approves the surgery claim.

sue in ne · 05-01-2009, 01:16 AM

monylove, it gets confusing. i , too was pre-approved and my surgeon had the authorization in hand. But i, too had a notice from the insurance company saying they had to determine if they would pay the claims. I also got bills that were denied.
1st, pre approval means you meet the criteria for thie funding the surgery. Once the surgery is done, the insurance company will go over everything to assure the necessity is the same.
2nd, i found the physician's bills were being denied. It turns out all bills related to the surgery are suspended until the case is reviewed and they don't review it until the hospital claims come in. Sometimes the claims are denied instead of suspended. I had the surgery 12/1/08 and just got the final notice from the insurance company yesterday. Your time frame for this is about the same as mine. I think it is a poor practice to deny instead of suspend a biller and why don't they notify the biller ??
Do Call the insurance company and find out about the bills that were denied and what is their process. Also, your surgeon's office can help you appeal any denial. (but I don't think that has happened )

gidgett · 08-19-2009, 06:47 PM

Can anyone give me some advice...im stuck. I just applied for Healthnet and turns out they dont cover the LAP-BAND® or ANY weightloss surgery. I dont have any money to pay out of pocket and I dont think I could afford the monthly payments of carecredit....HEEELP!!!!!

sue in ne · 08-27-2009, 09:21 PM

Gidgett, All insurance companies say they do not cover it t. But Most have criteria which if met, they will pay for the surgery. If you have a surgeon, check with his office.They deal with insurance Companies all the time . Ask here, esp in the Oregon groups. Sorry, I'm in NE and don't know your ins. Co. My insurance covered it in full. Others i know went to Mexico, cost was 2/3 of mine; even with the travel.