DS approved Crap Band Removal DENIED AGAIN

[Yvonne]

@Larra and @DianaCox

So I received more information on the DS approval with no mention of taking my band out. I received the approval last Friday in less than 24 hrs (Code 43845 - apparently the "bigger" DS procedure). I called on Friday, Monday, Tuesday and Wednesday I finally asked to speak to a person and not a voicemail. When the woman I was looking for got on the phone she clearly had laryngitis and that was why she had not called me back. That and she was having coughing fits the whole conversation. She did apologize and said she should have had someone else call me. They had not received the fax or the paper saying I was approved (I just received mine today).

She told me on Wednesday that she would have someone call BCBSIL and find out what happened. So the assistant in insurance called me back that day and said although they submitted in the letter to have my band out, it was not included in that code and they needed to resubmit. They resubmitted it on Thursday and today I got the news that it was DENIED!! They will pay $28,000 for the DS but not pay to remove my crap band.

For some reason they resubmitted these codes

43774 - Lapband removal
43775 - Laparoscopic sleeve gastrectomy
43659 - Laparoscopic miscellaneous procedure of the stomach

That is the EXACT codes my EX-surgeon used that was denied TWICE. In fact they told me that today. They did not tell me why it was denied. I forgot to ask. I am at a total loss. I am sick and tired. I don't know why they won't take care of me. I don't understand this at all. I'm beginning to wonder if there is hope of me having it at all. My husband said he doesn't think it's going to happen, because he's the pessimist in the house.

 

[DianaCox]

It appears to me that, with the DS approval, the latter two procedures are irrelevant. They only should have submitted for the first code.

The DS cannot be done without removing the crapband. Your surgeon needs to request a peer-to-peer with the medical director of the insurance company.

 

[Yvonne]

I was going to tell them that Monday. Last time the other surgeon tried peer to peer, he was given a miscellaneous doctor who said "not sure why they gave you to me, I font know much about bariatric procedures. I'll just pass this information on. " it was ridiculous. They counted is as an appeal. A wasted one for sure.

 

[DianaCox]

If you have the right to external medical review, getting your internal denials out of the way is not a bad thing - gets you to the EMR stage quicker.

 

[Yvonne]

We do have one. I've heard Dr. Inman is pretty great at peer to peer. I'd say by her personality that she's doesn't let go.

 

[Larra]

One other option if all else fails - and I realize this is somewhat unappealing but I'll mention it anyway - is to go ahead with the DS that the insurer will now pay for and self-pay whatever is extra for the lap band removal. I have no idea what this amount would be (or your financial situation) but given that you would already be under anesthesia, no extra hospitalization fee, etc etc it would be far less than a self-pay for a DS.
but of course do all you can on the appeals front first. AND, if you can afford whatever the self-pay would be, since you have already received a denial your appeals rights are vested (I think that's the right word) so you could continue appeals for the lap band removal coverage even after the surgery is done, and if you win they have to reimburse you. Of course if you lose, you don't get reimbursed.

 

[DianaCox]

Larra is right - if you can self-pay for the lapband removal NOW and appeal their denial of paying for it later (you have an official denial, so your appeal rights are vested - you should have six months to appeal), I would strongly consider going forward with the DS approval while you have it, get surgery, and appeal for reimbursement afterwards. Seriously, those insurance MFers could try to retract your DS approval - I'd go for it now if you can pay for the crapband removal yourself as an add-on - it shouldn't be that expensive, maybe a couple of thousand at most.

 

[Clematis]

All this is just absurd. I'm so sorry for the trauma, Yvonne.

 

[Yvonne]

I'm considering that. I could make payments for the removal, but would not be able to come up with a lump sum. We have HORRIBLE insurance now. $7000 deductible and 70/30. January 1st it goes to almost $10,000 deductible and 70/30. We've already paid (or are paying on) over $10,000 from all the tests and requirements from the 1st surgeon. We are financially in a pretty bad spot. My husband works 7 days a week and builds furniture to sell on his free time. Which is why running into next year is so critical. Our insurance got worse

 

[Yvonne]

Fairly certain Dr. Inman would take payments as they mentioned that if you have insurance. Good thing too, we have almost reached out out of pocket maximum. Which means about 90% of the DS will be paid at 100%.