Christina_TX

Post surgical insurance issues, need help!!

3 posts in this topic

I am having significant abdominal pain. I had RNY bypass 5 years ago. I have done a number of tests, including swallow tests and EGD and they are unable to find the cause of pain, but he thinks it may be something he's not able to see on the scans. He wants to go in for exploratory laparoscopic to check since all the tests have come back negative. I'm miserable. 

The office was trying to get me scheduled for surgery today (Monday 3/6) but they had to get pre-certification. The nurse called to check on my pre-certification, and she said I would most likely be declined for the surgery. She says they do not cover bariatric procedures. I called and explained this isn't a weight loss surgery, but due to abdominal pain and she (very rudely I might add) said it doesn't matter, they won't cover any complications either. 

I have a secondary insurance policy, I also called them. They stated they only cover 1 bariatric surgery per lifetime (even though they didn't initially cover mine), and again when I explained it's not weight loss she basically said the same thing. At this point I was crying hysterically because I am afraid that I'm going to have to live with pain and there is something wrong that they can't fix. She said they only cover "removal." I'm not sure if that's reversal or if they are talking about like removing a band.

I haven't got to the process of appeals yet because I don't officially have the denial, but I talked to the nurse case manager and she pretty much said yeah it's under review but you are going to get declined.

I had NO idea this would happen! I knew that it was difficult to get insurance to cover bariatric, and I was lucky with my original plan that did cover it. But now that I have changed insurance due to my job, I didn't realize that none of my potential complications would be covered. I don't know what this means for me. I am so upset, and had I known this, I would have NEVER got this surgery! I didn't do my research well so I can't blame anyone but myself.

Help, advice, anything?

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my insurance will not pay for anything labeled bariatric not even the yearly visits. will not pay for blood work if it has weight loss or bariatric in the coding. see if they can code it another way.

Res Ipsa likes this

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Have them check for bowel intussception or blockage. I had low left pain and ended up getting my bowels resectioned. Don't mention that you think it has anything to do with bypass at all.  I hope your insurance company will work with you before it becomes an ER visit. Good luck

Res Ipsa likes this

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