DENIED AGAIN!

[Amey]

BC of ID just updated their website. Lap Band removal approved.... DS denied. I meet Medical Necessary requirements. WTF??

 

[Larra]

You need to get the justification for the denial in writing. And I can't remember whether you already have your EOC and documentation of what your appeals right are. Once you have all that collected we can figure out how to proceed.

I'm tagging @DianaCox just in case she doesn't see this (probably unnecessary).

 

[Amey]

Yes I have the provider document and my Explanation of Coverage... Hell I quoted the section on weight loss surgery on my letter. I have the right to appeal, a peer to peer and the last step, 3rd appeal, is a request for an outside party to review the documentation to make a decision.

 

[Amey]

I probably won't see a letter for the denial in my mailbox for 2 weeks... But I might be able to get the surgeons office to fax me what they get.

 

[DS fan]

What was their reasoning for denial?

 

[Amey]

Same as before... Not medically necessary.

 

[DS fan]

Gah!!!! Keep fighting !

 

[Amey]

I plan on fighting for as long as it takes!! But I feel like I'm fighting blind. And at this point I'm thinking that maybe I should get my band out asap before any more damage is done and let my stomach heal and maybe my Barretts will improve while I'm fighting. Part of the reason they are denying it is because they are saying is a revision.... If I don't have a lap band then it won't be a revision anymore. And hey maybe I'll gain 100 pounds and have diabetes too (sarcasm). I just feel really defeated... But I'm not giving up.

 

[DS fan]

Best of luck to you !

 

[Larra]

@Amey even with the lap band out, it would still be considered a second bariatric surgery. the key is whether or not you have coverage for more than one bariatric surgery, whether medically necessary or not. Many policies only cover one bariatric surgery per lifetime, even if the first one was a total failure. So we need to review the exact wording of your policy and any appeals need to take this language into account. In other words, medical necessity isn't always enough to get coverage. Sad but true.
But you might decide anyway to go ahead with the lap band removal. You are the one living with it, not any of us. That has to be your decision.

 

[DS fan]

That's what I was thinking too Larra. I was hoping a vet would speak to this.

 

[Amey]

I think I uploaded my EOC before when I was denied the 1st time but it's not letting me now... I think it's too big. Is there another way I can send it?

 

[Larra]

Start a conversation with me and Diana and email it to us. I don't know how to help you post it here.

I'm also thinking that if the ONLY reason they gave proves to be lack of medical necessity, and NOT that you don't have coverage for revisions, we would have a much easier time of it. Again, we need the written denial. If you can get it from your surgeon, fine, if not, we just have to wait for your copy to arrive. Our hands are tied without this.
I think Diana is away on her RV trip but she does check her emails and respond, it just takes a little longer. So again, a conversation, or email to the two of us, would be helpful.

 

[Amey]

They denied it for the exact same reason as the first time. I will get that scanned and email it to and Dianna with my EOC.

 

[DianaCox]

Just checking in - busy day today in the Phoenix area.

What Larra said - we need to see the exact wording of the denial, we need to see exactly what was sent to the insurance company, and we need to review the EoC again - if you can put them all in the same place for us to review, that would help.