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Post by angie00708 on Jan 10, 2012 16:44:01 GMT -5
I have BCBS/TX insurance that covered by RNY surgery 2.5 years ago, no problem. They also cover revisions with a laundry list of qualifications. I qualify for all of them except one for the revision to DS. There is a minimum BMI of 50 for the DS. I have a current BMI of 41. My RNY has failed me - I haven't even lost 100 lbs. since surgery with being completely compliant in diet and excercise. My surgeon agrees that the DS would be a better option, long-term and is willing to write a letter for insurance purposes. I have not submitted a claim YET but would consider an appeal for a denial if I thought it might be successful. Is anyone aware of success when it comes to something like this? Thanks in advance.
PS - also posted to insurance board.
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Post by lovy19 on Jan 10, 2012 16:51:25 GMT -5
Hello Angie, Welcome to this great site. I know that when one of the vets see this post they will respond. The information here about the DS and other surgeries are amazing. You have come to the right place when asking insurance questions. Wishing you the best of luck on your weight loss journey  . |
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Post by sandyv63 on Jan 10, 2012 17:09:49 GMT -5
You've got a decent shot at winning this on appeal, but not an internal appeal so prepare for a fight. There is no basis for requiring a BMI of over 50 but your insurance will probably keep denying you until you get to an external review. One of the vets with insurance experience will likely chime in soon with even more advice for you. Don't give up!
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Post by Band to DS on Jan 11, 2012 13:26:49 GMT -5
My insurance company also has a BMI requirement of 50 for the DS. My BMI is in the mid 40s. I've been fighting them for a lap band to DS revision since this summer. So far, my initial request was denied, a peer-to-peer review was denied, and my Level 1 appeal was denied. I'm working on my Level 2 appeal now. When that gets denied, I will request an external review through my state's department of insurance.
My advice is to learn everything you can about your insurance policy and the appeal process with your insurance company. It might be a long, emotionally draining battle, but it's worth trying. There are lots of people here who will support you.
Shelli
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