disney38

I am contemplating out of state surgery, but the problem is that the local surgeons here will not fill for a patient they did not do the surgery for. Is this common? If so, do you travel (for me it would be by air) for each of the fills and appointments? How often? I am looking at the doctor in Colorado, as that is about $8,000 cheaper than my local surgeons. I think I could go there a few times and still be money ahead. Thank You.

I do think 239 is high enough if you have tried to lose weight on your own and cannot. I am not banded yet. My insurance denied last August, and denied the appeal. I have resubmitted with uncontrollable sleep apnea. That being said, I weigh 240 lbs and am 5'6" tall. I have tried for 18 years to lose the weight. When I had my youngest son (who will be 19 in July) the day I gave birth I weighed 209 lbs. I was appalled! This was 9 months pregnancy weight on top of my weight. I never saw below 200 again. Well, not entirely true. I did fen-phen and lost 80 lbs and was loving life and feeling health and full of energy and sleeping well. That of course didn't last. Every diet since then, I will lose SOME weight and gain it all back plus. Not trying to argue at all, but my health is deteriorating every year. Now my blood pressure is high and I have high cholesterol. My insurance won't count those though, cuz I would have to be on medication, and have that not control it to be counted as a comorbidity. I am 46 years old, and as tired as a 70 year old woman. I go to my job and I come home. I have been walking every day, even though it winds me to do so. I am preparing my body for surgery, as with or without my insurance, I am having it done. If insurance says no, I have a date in June in Mexico. So, my struggles over the past 19 years make me say that I do believe 239 lbs is high enough if you have struggled for a long time. I have had my gallbladder out, recently a hysterectomy due to fibroids and ovarian cysts (which the gyn said was made worse by obesity, as when you are obese your body creates more estrogen, and estrogen feeds both fibroids and cysts. Sorry, didn't mean to write a book. This one just caught my eye. Have a nice day everyone, and good luck with your decision.

Once your insurance denied your coverage, or you just simply chose to pay for it yourself, did you tell you insurance company you were having this surgery? I am on the fence, and very frustrated with my insurance. I guess they want me to have a stroke before they cover, but I aint waiting. My concern is whether or not I should tell them I am doing it. If there are complications later on, I heard that sometimes insurance will pay. However, if I tell them ahead of time, they may decide to be nasty. Thanks

Your poem is my life too. You brought tears to my eyes. No one but those of us LIVING this struggle can understand. Thank you for the emotional poem.

I feel your pain. I am 5'6'' 240 lbs. I tried unsuccessfully to get approved for this surgery last summery. Because my BMI was not 40 (39), my insurance said no. Long story, but health issues and hysterectomy made me wait with pursuing, but I am pursuing with a vengeance. My DH says I need exercise. My mom thinks I don't need the surgery. I know I do. I don't sleep (sleep apnea), I have no energy, I have headaches all of the time, and now my BP is going up as well. I am trying ONE MORE TIME to get this covered by insurance, but I have already decided it is time to take charge of ME. I am having this surgery whether insurance pays or not. It is time for ME to be healthier, so that is what I am going to do. I will tell very few people, because they will not be supportive, and I do not need that. Good luck. You will love this board.

but will tell of my experience. I was denied by my insurance (BCBS) because my BMI is not 40..it was 39 when we submitted for approval. I had just been diagnosed with sleep apnea prior to submitting. They denied my request and the appeal because: BMI greater than 35 and less than 40 would be considered with comorbid conditions. They did not count my Sleep Apnea because it was controlled by CPAP. I had only had it 2 weeks, and had no time to see how it is working...it is not. At any rate, since the denial (8 months ago) I had some other health problems and left this be. Two weeks ago, I called my insurance company and they said i could resubmit ONLY if something changed. So I asked them about the sleep apnea not being controlled, they told me that did count. Now I do have high blood pressure and high cholesterol - they won't count it because I am not on medication. If I go on medication, they won't count it because it will be controlled. The surgeon is submitting for the sleep apnea, but if this fails again, I am a self pay to Mexico.

If your BMI is 40 or above, they typically approve quickly without comorbidities. My problem is that my BMI was 38. If your BMI is 35-40 and you have a life threatening comorbidity (diabetes, high blood pressure, high cholesterol, sleep apnea, etc) and the comorbidity is not being successfully treated, it should get approved. I am trying again, as some things have changed, and some of my issues are not controlled anymore. They (Meritcare) usually have a pretty good idea of who will get approved. I did all the requirements before I saw Dr. Monson, but for whatever reason, insurance didn't approve. Good luck to you.

I was on lexapro a couple of years ago. I struggle with sleep issues, and most of these types of meds have side effects of either making you tired or making you not tired. It had the "make me not tired" effect on me. No matter what time of day I took it, I had terrible insomnia at night. I am currently on prozac, and so far so good. Lexapro is a very good medication, it is just me that it didn't work so good on.

By the way, this board ROCKS! Everyone is so helpful, I am really liking it here. I am not YET banded. Still jumping through ONE MORE HOOP to see if POSSIBLY insurance will reconsider. They denied me last August, but since then my BP and Cholesterol are high, and my sleep apnea is not controlled well by CPAP. It prolly would be if I didn't take the darn thing off in my sleep all night long. OK, I am wandering here. If insurance denies AGAIN, I am doing the band in Mexico. I have it scheduled right now for April 30th, but I may need to change it by a couple of weeks. My son is graduating from high school, and we are having his open house on May 26th. Will I be up to hosting a party and cooking 2 weeks post op if I have to change the date? My other alternative is to wait until afterwards, but I SOOOO do not want to wait. I am ready to start living again. Thanks!

Thank you all for your comments. I do feel a lot better about scheduling this prior to graduation. I know I will have TONS of help if I want it. This is my BABY graduating. His two older brothers and my DH can do all the hard part!

Wow - you are doing great! Actually, my insurance DOES cover banding, and I did jump through the hoops, and they denied coverage to ME. Why, because my BMI is 39 and not 40. If I knew then what I know now..... I was diagnosed with sleep apnea at the sleep study. I got a CPAP and initially WAS sleeping better (only had it 2 weeks when denial came through), but the reason why it was denied was because I did not have a comorbid condition with a BMI over 35 but less than 40. They did not count the sleep apnea, as my records said "controlled by CPAP." I am now experiencing high blood pressure (not extermely high - 142/95), but if I were on medication for that (I am not), they won't count that either. I am a bit irritated with my insurance company. I have been to hell and back in the past 7 months. Anyway, surgeon has one week to figure out if they will fight for me. If not, I am going south - actually, have a date scheduled in Mexico if this falls through. I am not holding my breath! :cry

I am in your shoes as well. My insurance denied the pre-authorization, however, I am trying one more time. That being said, I have a date scheduled in Mexico. I will wait to see what happens with insurance, but not holding my breath. I have convinced my husband this is a good thing, and I am doing it with or without his support. He will go with me.

I was as close as you (and I had sleep apnea besides), and my BCBS denied my surgery. I was tempted to gain the 10 lbs to get me to 40. My insurance has a requirement that you have to be at that bmi documented for 3 years. I figured for me there was no use, as I am not waiting 3 years. Since my denial (and subsequent appeal and denial), my blood pressure has become elevated and my cholesteral has raised. I do not know if this will help get approved or not, but I am trying one more time. I also have a family history of bad things, buy my insurance would not recognize that as a comorbidity for me. Can you tell I am a tad disappointed in my insurance. At any rate, I am getting surgery in the next couple months I think. I will self pay, probably in Mexico. I have done a ton of research, and I am presently thinking of Dr. Ortiz. I have been preapproved for a loan for the procedure, now I am just waiting to see what my surgeon and/or my insurance will do. Hope you have better luck with your insurance. I finally got to the point that I need to do this to improve my health. It is sad that my insurance company doesn't see it that way. Good Luck

for surgery? I know I am either going to Colorado or to Mexico, neigher of which are close to where I live. When you have this surgery out of area, did you set up your after care provider prior to surgery? Is the only aftercare fills, unless there are problems? Anyones experience would be greatly appreciated. I guess I am a little nervous, though haven't scheduled yet, but I WILL! Thanks

My insurance is BCBS of ND AND I have two policies with coverage. I was turned down because my BMI was not 40. It is 39.....but, I was diagnosed with sleep apnea 2 weeks before the request was submitted. At the time, the CPAP worked OK, because I was sleeping so horrribly. They denied because they said I did not have a co-morbid condition and the surgery was not medically necessary. They didn't count the Sleep Apnea because it was controlled by CPAP (for 2 weeks). They appealed, and still denied. The second denial happened in August. After that I was defeated. Shortly thereafter (September), I had some medical problems and had to have a surgery that made me put this on the back burner. I have since recovered and am more determined than ever. However, between August and now, the CPAP is not doing the job anymore....it only lasted a few weeks, and I am not tolerating it well at all. I remove the mask during my sleep and wake up several times. When I spoke to my insurance, they told me to resubmit....so we will see. I am determined one way or another to do this. I am a tad nervous about going to Mexico, though I like their price. Bismarck is $13,000, Fargo is $17,000, and the Dr. in Colorado is just under $10,000. Lots of information, but I am very happy to find some locals on here, and now you understand why I was not approved. If my BMI had been 40, it wouldn't have mattered if I had co-morbidities, insurance would have covered. However, the BMI had to be that for 3 years. Thanks

nice to see this thread! I am on my last resort to getting my insurance to cover surgery. They denied, then denied my appeal, but lots has happened in the past few months...they MAY reconsider. Either way, I am having surgery - not scheduled yet. If my last resort with insurance doesn't work, I will either go to Bismarck to Dr. Schmitt or to Colorado to Dr. Schmitt, maybe Mexico, but a little unsure of that yet. I live in Fargo and have seen Dr. Monson. I did just find out today that Meritcare will now do fills for patients that had surgery outside of Meritcare - that was not the case last Fall. I too want my health back. I have tried and tried to lose weight, but it just doesn't work. I hope the band will be the tool I need.

so I have been researching lots on this website and other places. I found a doctor whose weight loss coordinator can't figure out why I got denied, and thinks she can get it approved. I have a BMI of 38 and have sleep apnea. They denied me because the sleep apnea is controlled by CPAP. Long story, but I did my sleep study last July, got the CPAP, and had a follow-up appointment with the sleep doctor. Truly, I did sleep BETTER, but by no means do I sleep all night without waking up a few times. If I knew then what I know now...... At any rate, I do not think I am handling the CPAP very well. I take the thing off in my sleep (or my awake) and don't even realize I had done it. I have a doctor appointment this week where I hope they will document in my medical records that I am not sleeping well even with the CPAP. I have also committed myself to paying for lap band surgery. Now I am in a quandry. I really would be much happier having my insurance pay for this, but not sure I can handle another denial. Anyone who has been denied, have you ever gotten it turned around? My appeal was denied too, but at that time, I think the CPAP was rather new and I didn't have much time with it. I have decided if I am self pay I will go to Colorado to have this done with Dr. Kirshenbaum. For those that did this, did you have air travel? Were you able to travel right after surgery? Would you recommend this doctor/clinic for this? It seems that what I have read has been very good. Also, my biggest fear of all is that I will fail. My DH has seen me go through much money on many different diets. I KNOW that the lap band itself will not make me lose weight, but I am hopeful that it will help me. Any comments greatly appreciated. Thank You.

But I have not had surgery YET. I went through all the requirements at Meritcare, had a consultation with the surgeon last summer. They just started doing lap band surgery at Meritcare in September. At any rate, my insurance turned down my request and also denied my appeal. Another problem was that if I had my surgery somewhere else, Meritcare won't do the fills. I just today talked to a doctor's office in Minnesota, and for the life of her, she can't figure out why I was declined. My BMI is 38 not 40, but I have sleep apnea. Anyway, I am getting together all of my medical records and sending to this doctor in Minnesota. If she can get me approved, groovy. If not, I am having it done in Bismarck (a little less expensive) and paying for it myself. All the research I have done indicates that you would normally be off work approximately 1 week. Some places say 2-3 days, but mostly I have heard a week. I plan to NOT tell my co-workers why I am going to be gone. I will probably be attending support group at Meritcare even though my surgery won't be there.

Wow, I was skeptical about posting my question, but I am soooo glad I did. Thank you for all the information. I told my husband today that I AM going to do this. I did all the preliminary things like supervised diet, psych evaluation, yada yada yada...I want to do this before they make me re-do all of that. Thanks again!

I live in Fargo, North Dakota. Minnesota is just across the river from me, so that would work too. I know in North Dakota there are surgeons in Bismarck, Minot, Grand Forks, and Fargo. I would even consider South Dakota, Sioux Falls, Aberdeen. Thank you for looking. The surgeon I have seen in Fargo I do know will not fill for other surgeons.

This seems dumb, but I am going to ask. I have about given up that insurance will pay, not entirely, but I am close to determining that if I want this done I will have to pay for it myself. Has anyone who paid for their lap band surgery themselves had any issues down the road with your lap band? If so, I assume that is not covered by insurance as well. Is that correct, or if you have problems later on and require some medical attention, has anyone had their insurance company pay those claims? Thank You.

Hi I do not have surgery scheduled at this point, but am contemplating a self pay lap band surgery. My BMI is approximately 38, I have sleep apnea, joint problems, and a horrible family history of cancer, diabetes, high blood pressure, and heart attack. I applied for RNY surgery in July and was denied. The surgeon appealed, and it was denied again. I about gave up. Then I got diagnosed with female problems and had to have a hysterectomy. I know in my heart this is partially from being overweight. I had a very large fibroid tumor, which is fed by estrogen. I also had stage IV endometriosis, which is fed by estrogen. Estrogen is made in abundance when you are overweight. I digress......my area just began doing the lap band surgery in September. I want to try my insurance again. If not, I am thinking somehow someway, I will find the money to self-pay. Thanks for listening.