HAP HMO denial - what can I do?

Question

I was denied Duodenal Switch bariatric surgery "due to the lack of evidence to support the long-term safety and efficacy of this procedure. In addition, the mortality and complication rates are higher than that of alternative Bariatric surgical procedures." I have been approved for Roux-en-Y gastric bypass.

Does anyone know how I can convince my insurance company that the Duodenal Switch is the right procedure for me?

Answer 1

It sounds like its still somewhat experimental & unproven/new. You'll need to do some research, & starting digging for proof that they're wrong. & then, appeal their decision. If the are right, then they won't approve it... sorry.

Answer 2

~~You would have to enlist your doctor to provide the medical necessity to change their decision. I guess you could hire an attorney to battle in court, but it's a costly and long battle. Maybe with the complication worry you could investigate it further, you may change your mind. It sounds scary the way the insurance company stated the decision for the denial. I hope everything works out for you, best of luck!~~

Answer 3

The language that you quoted sounds like the standard "we consider that procedure to be investigational and don't cover it for anyone" language.

You can ask HAP if they consider the procedure to be "investigational."  (Based on the statement you quoted above, I'm about 99.999% sure that's the case.)

If its considered "investigational" by HAP, then there isn't much you can do about it.  You can try having yourself and/or your doctor sending in scientific research about the procedure you want, but keep in mind that to change their position on considering it "investigational" would mean that they would have to change their entire stance on the surgery for everyone.  I wouldn't be terribly optimistic about that happening.  Sorry.

Answer 4

I don't know how to convince your insurance that but there are other ways to still save and get the surgery done.  I know of a great discount health benefits company that accepts everyone.  If your interested send me a message or im.  Good luck!