Struggling through the DS insurance approval process

[Kurt Griskonis]

Hi,
I chose DS almost 2 yrs ago. Got approved by my health care provider for DS with the ONLY DS surgeon who takes my company insurance in Southern CA. April 2014, I broke my foot the night before pre DS surgery check in. Took my foot 9 months to heal, which delayed my DS.
Now I am ready to get "reapproved", same surgeon, same insurance company.
My Dr (Keshishian) found out he has been "uninvited" as a provider for Cigna. So now I do not have any doctor in CA that can do my DS surgery and have insurance cover it.
So far, I have been told my alternatives are:
1) appeal to my insurance provider to cover my surgery with Dr K "out of network" (bariatric surgery is not covered out of network in my plan)
2) Pay cash for the surgery
3) Go with traditional Gastric Bypass or Sleeve with an approved surgeon in San Diego (a non starter for me)

Does anyone have any other ideas?

 

[Larra]

Kurt, @DianaCox can probably answer this one better than I can, but we've seen other cases where out of network Ds does get covered when there is no DS surgeon who is in-network. You will need to get your EOC (evidence of coverage) which is a lengthy document, not a little summary, to see all the details. You will also need to sort out whether your insurance is self-funded or fully funded (again, Diana understands this better than I do). If Dr. K is no longer in their network, I very much doubt that another DS surgeon is in-network. so, if your plan covers the DS, it's not your fault if they don't have an in-network surgeon who does it, so they should cover your surgery with Dr. K. At least, that's how the argument goes, and it is often successful. If not, your EOC should tell you what appeals avenues you have, if any.

another possible avenue of appeal might be, in your case, that you WERE approved before you broke your foot, I presume by the same insurer.

 

[DianaCox]

Also - is your insurance fully-funded or self funded? Ask your HR department for this information as well as for the EoC document.

 

[Whit]

Glad you made it here Kurt. You deserve to be healthy. Don't give up!
All my best,
Whit

 

[brooklyngirl]

Welcome, Kurt. Hope you can get the answers you seek!

 

[Charris]

Welcome Kurt, talk about luck. Well don't give up because that's exactly what they want you to do. Give them HELL!