Denied~Not medically necessary

[Margaret Schraub]

HI. Today I got a call from my surgeons office regarding my DS, she said I had been denied.
I called Anthem BC/BS and asked why. I was told after being transferred here and there and calling again that it was not medically necessary.

A little bit about me....I had the band in 2011 and had it removed in 2014. I went on to have the VSG 6 weeks after my band was removed. Neither of these things has worked for me. I have followed the plans on both of them. I went to a different surgeon and his first response was....why did you have these done and not the DS? My previous surgeon recommended them both. Now to think back, if one restriction surgery didn'tn work....why would another one. My metabolism is broke!

My starting weight was 330 lbs my current weight after both lapband and VSG is 296. I am 5'2. Carrying this much weight around is killing me.

I was also told by insurance that my sleeve had been stretched out from over eating....Ummm I've had not testing that states this. I still have restriction...why would they say that and put it in my denial letter?

What should I do to appeal this? I am just dumbstruck right now.

 

[Larra]

Hi and welcome! We are seeing more and more people wanting revision from other, failed operations to the DS all the time. I just wrote a lengthy reply to @sylie, who has received a denial for a RNY to DS revision. Check out her thread (there are 2 of them, I replied on one, should be easy to find) as it will give you lots of info as to where to start.

I will throw in more advice for both of you here - document EVERYTHING. that means not only keep all correspondence and emails, but also document every phone conversation with your insurer - name and job title of the person you speak with, phone number, date, time, and a summary of the conversation. And if you get the run around and non-answers, always request to speak with a supervisor. The people at the low end of the food chain who answer these calls are not experts on bariatric surgery coverage, they answer all kinds of calls. Some are very good and really try to get things right, others don't care and are just putting in the hours. You need to know your policy for yourself. No one cares about this as much as you.

btw, your bmi is 54.1. Anyone who says that the DS isn't medically necessary for you is an idiot. But I bet they're going to deny based on your alledged noncompliance. We see this all the time.

 

[DianaCox]

Get your medical records too - you need to see what your doctors have said about you (which will most likely be ass-covering BS blaming you for the failure of the procedure THEY gave you, which was never going to be good enough for you).

 

[Yvonne]

You are almost in the exact same boat as me. So sorry. They approved my DS (although had denied it twice before) but won't pay for my crap band removal. I am 5'3" and 320lbs. We are VERY close with screwed up metabolisms. My Endo told me years ago (2005 is when I got my band), not to get it as he's seen me eat 800 calories and not lose weight. Screwed up metabolism as well. PCOS. Good luck. I'll be watching what's going to happen for you.

 

[sylie]

I am documenting everything and everyone I speak with from the ins company- the bariatric surgeon who originally did my RNY has convieniently decided to retire (he almost killed a co worker of mine) and getting medical and operating room docs were tough but I got em. DS was never offered to me as an option -I HAD to go with what he offered me- my surgery was done in 2008 but my friend WAS given that option....hmmm curious