Denied for only being on 1 med

christellini · 06-08-2007, 01:55 PM

I haven't been in here for a while. I received a denial from my insurance and have just been discouraged. I was denied due to only being on 1 med for hypertension and they only approve if your taking 2. Okay, I thought that was what I was trying to avoid. I feel like this is so stupid. Anyway, my Dr Office said they are still working on it but I know how insurance is and am not feeling very hopeful. It's like okay give me time to age and I'll be on more meds I'm sure then you'll approve me and what exactly is this accomplishing???? Sorry, little rant there.

I'm thinking about self paying, but then what if I have complications, will I be responsible for paying for everything related to the band since they denied? Anyone know?

Christel

anonemouse · 06-08-2007, 02:19 PM

From what I understand (don't take this as gospel), insurance will pay for procedures if you have complications because they will be considered "medically necessary." For example, if you have erosion or slippage, they would pay for the removal of the band. This is only if they consider it "medically necessary," though. If the surgery just doesn't work for some reason, and you want the band removed, they won't pay for it. But if you do have complications like slippage or erosion or esophageal dilation, they'll pay.

cyndilou29 · 06-08-2007, 07:15 PM

I think Lauren is right. I did it completely self pay and I had a few complications in the beginning. The hospital included the "extras" that I needed in my original fee. We thought we might have to remove the band because I wasn't getting anything down (it was swelling related) and my insurance would pay for it. Anything that is medically necessary, they will pay. Mine just didn't think putting it IN was medically necessary. They stink.

christellini · 06-09-2007, 12:32 AM

Thanks for replying. I am looking into it, it may be my only option. It really does stink that I am trying to lose the weight so I can get off meds completely and they deny me because I'm not on enough meds. What also bites is that I try to eat healthy and exercise which is what probably kept me from having more problems and ends up biting me in the butt. Thanks again ladies.

joanne1970 · 06-09-2007, 01:13 PM

my insurance denied me twice saying that my hypertension wasnt severe enough, I also was taking 1 med, I didnt take no for an answer and sent in an appeal, it was approved by an independent reviewer and I got my band on 6-5 DONT GIVE UP! They dont want to pay and will try everything not to. I even looked into going to mexico so I feel your frustration. I'll keep my fingers crossed for you!

christellini · 06-09-2007, 04:36 PM

Joanne, Congratulations on your surgery. Hope your doing well. I'm glad to hear your story, makes me feel like I still have a hope. I will call my surgeon's office on Monday and see where I should start.

blulili · 06-09-2007, 04:45 PM

Hey Christellini--
So sorry to hear about your insurance headache. We are in a similar situation. My insurance denied my husband's request for a RNY gastric bypass. Twice. We appealed. Denied. Huge mess and he was so disappointed. Our insurance does not cover the LAP-BAND^®. So...all that mess to say that we're self pay and are going into Mexico to have his LAP-BAND^® done 7/18/07. It's such a shame that insurance companies don't focus on the future and the money they can save by covering these surgeries so that people CAN get healthy, can get off meds and can end up saving them money. Ugh. Sorry for the rant....but I feel your pain. Good luck to you, and please, don't give up without a fight!
Take care,
Lili

christellini · 06-10-2007, 02:36 AM

Lili, thank you. I'm sorry to hear about your insurance problems. I just don't get it. I'm only 34 with hypertenstion, PCOS, high cholesterol, and
insulin resistance. So what my future looks like to me is diabetes and heart disease. Ugh, makes no sense. I had totally given up for a while and thought self pay was the only way to go but I've got some fight back in me somehow and am ready for it. Good luck to your husband too!!!

isabelle290 · 06-10-2007, 04:29 AM

I know exactly how you feel. My insurance gave me the run around and didn't end up covering me, even after two 6 mo. diets. The best thing to do is to ask your ins. to send you a copy of everything that is covered and everything that is not. Half the the time, the people working on your claims deal with so many policies, they don't know what they are talking about anyway. I heard in the next few years, all band surgery will be required to be covered. In the meantime, the ins. companies try everything they can to save a buck and not cover us! Apperently they could care less about our health!

Raven5683 · 06-10-2007, 10:42 PM

Christel,
Have you had a sleep study? You should have one done...if you happen to qualify for Cpap (sleeping breathing machine due to sleep apnia), then you would qualify because that would be your 2nd comorbidity...The second option would be to have all your labs done and see where you stand. Maybe your PCP would put you on a second med (if needed) to help get you qualified.
Good luck
Hang in there!

christellini · 06-11-2007, 12:01 PM

I did have a sleep study done about a year and a half ago and everything was within normal range. I just recently had my labs done for my surgeon and my PCP has them, I could call her and see what she says. What sucks is that at one point I was on 2 meds for the hypertension and I started exercising like a maniac and she was able to take me off of one. Although she supported my decision to have the surgery and she wrote the letter for me I really don't think she approves. Which, actually, it's not her job to approve or not so I can try her out. I also have an appt with my endocrinologist on Friday, I haven't seen her since I made the decision to be banded so not sure what her thoughts will be but she may be able to help too. I wrote this really quick, I hope it all made sense, gotta get to work. Thanks to everyone.

uniqueone · 06-11-2007, 12:51 PM

I have never heard of anything so stupid and downright illogical in my life!!! Don't they realize it will cost them much MORE money in the long run?? Hang in there! I'll think good thoughts for you.

christellini · 06-11-2007, 04:09 PM

Uniqueone - you get my drift!!!

Big As Life · 06-11-2007, 04:14 PM

I am so sorry to hear of your problems with the insurance...I hope that you will find a way to be banded...Maybe your doctor can help...I hope so....good luck...

LTjr · 06-11-2007, 08:49 PM

Hi christellini,
i don't know what insurance you have, but I know some will only cover RNY and not LAP. If you can't get the lap RNY may be the next best thing. I am from Mass. and my sister has the state run healthcare. MassHealth only covered RNY. It is bizarre to me that some companies will not cover LAP. Both surgeries help the same problem. I know LAP is more expensive, especially if it is done Laproscopically . I hope you can find a solution.