To prevent this from happening in the first place, make sure you're thorough in providing necessary lap-band insurance information.
However, if the day comes when you get a letter saying you've been denied...
...buckle down and get ready to start fighting it.
Accept the fact it's going to be frustrating and time consuming, but know that many before you have gone through the same thing and emerged successfully...
...with denials overturned.
Gastric Lap-Band Insurance: The First Rule in the Appeal Process: Keep Good Records
First things first. Get yourself organized.
Easier said than done sometimes, I know! Get a folder or set up a special file in your filing cabinet devoted to keeping track of this important information.
If the letter you received doesn't clearly explain why you were denied, contact your insurance company to find out! You may have simply left out a piece of needed documentation or provided insufficient information (e.g., the documented efforts you have taken to lose weight are insufficient).
Gastric Lap-Band Insurance: When You're Denied Due to "Lack of Medical Necessity"
You may have provided all the necessary information only to be denied because you didn't sufficiently prove the surgery medically necessary.
This really makes my blood boil. When you weigh 325 pounds, have a BMI of 50 and suffer from diabetes for example, I will never understand how you could receive a letter saying...
... "We're sorry...Your request for weight loss surgery has been denied because it isn't medically necessary."
(I can just picture a person sitting in a cubicle, hard at work with the "DENIED" stamp in hand..stamping one letter after the other...DENIED...DENIED...DENIED...only to receive a big bonus check at the end of the year for saving the insurance company a bundle....)
What they're really telling you is...We don't want to pay. Go back and try to lose weight on your own, even though statistics suggest you're 95% likely to fail.
Needing weight loss surgery because it's "medically necessary" can really be boiled down to objective measures like BMI and presence of health problems related to obesity (diabetes, hypertension, sleep apnea, etc)...
...but that's not always how insurance companies look at it. :(
If you've been denied due to "Lack of Medical Necessity," yet you meet the technical criteria (and have provided proof of it)...
...chances are you didn't provide good enough documentation of your past weight loss attempts, proving bariatric surgery as your last resort.
Gastric Lap-Band Insurance: When You're Denied Because Surgery is Considered "Experimental"
If your gastric banding surgery was denied because your insurance company claims the gastric band is "experimental" or "investigational," you'll need to provide clinical information that shows it's not.
This might include copies of clinical articles as well as third-party's recognition (e.g. Medicare) of the Lap-Band® System. Your bariatric surgery center should be able to help you with this!
Gastric Lap-Band Insurance: The Appeal Process - Writing a Letter of Appeal
Write a letter of appeal to your insurance company addressing the specific reason(s) for denial. Also include the necessity of the surgery and a detailed account of your past weight loss attempts if you haven't already.
Even though you'll be angry, keep the tone of the letter friendly :)
Gastric Lap-Band Insurance: Sending the Letter of Appeal
Always send correspondence via certified mail with a return receipt.
You don't want to go through all the trouble of sending meticulously gathered information only to have them claim they didn't receive it!
If you fax the information, make sure you get and keep a confirmation of when it was sent, how many pages were sent, who received it and how many pages were received.
You have 2 in choices in writing a letter of appeal:
There's no guarantee, but sometimes a lawyer's letter on the insurance company's desk gets taken seriously a lot faster than your little letter. It may be worth paying for help early on in the process. This could save you time and many headaches, especially if you wind up having to get a lawyer down the road anyway.
Use an attorney experienced in healthcare law and one who is familiar with issues pertaining to bariatric surgery. Use the search box below and enter
healthcare lawyer city OR
(fill in the name of your city: Example- weight loss surgery lawyer tucson
Dealing with your insurance company can be overwhelming! The Obesity Law and Advocacy Center is a good first resort to turn to if you get denied. If you are seeking approval for Allergan Lap-Band, their services can be free through the Lap-Band appeals program.
Gastric Lap-Band Insurance: If You're Denied a Second Time (Or Third Time)
Hopefully this won't be the case, but it is a possibility.
If your first letter of appeal wasn't successful in getting you approved, a second letter may be in order...and possibly a third. Your denial letter(s) should always tell you what your options are and how long you have to exercise them.
The Key to Winning An Appeal: Persistence
Be a Squeaky Wheel.
A squeaky wheel gets oiled. Stick with it!