Length Of Time To Get Approved

[Wendiss 0]

This insurance thing is killing me. I have the BMI and weight necessary for approval, but the documentation of supervised weight loss is a problem. Forget the fact I have tried numerous times in my life w/Weight Watchers, Sugar Busters, calorie counting, working out, etc... to lose weight and keep it off. Forget the fact that I am over 100lbs overweight, have high blood pressure, high cholesterol, and arthritis so bad in my knees I can barely walk 100 yards. Forget the fact I do have 6 months of documentation of a medically supervised weight loss program. All the insurance company is worried about is 12 consecutive months of this bleeping documentation.

Here are my questions to you all. I can get the documentation if I go back into the program I was with, but then what? I am being told by BCBS of MI that it has to be 12 consecutive months prior to talking to a doctor about the surgery. How long did it take some of you who did get insurance to cover your band surgery to get this approval? Better yet, how long did it take from the time you decided to get the band until you actually had the surgery? I guessing this hoop you have to jump through to get approval is the reason so many bandsters self pay.

SERIOUSLY FRUSTRATED

[MerryHearted 20]

What a pain in the butt. Sorry you are having such a frustrating experience. I think your insurance just doesn't want to cover it. After all, most people would lose weight over 12 months on a doctor-run program. But then we gain it all back!

If my insurance had required that much of me, I definitely would have gone self-pay. I've been dieting for years, some doctor managed and some not. I didn't need another 12 months of that.

For me, it was one month between the seminar and my surgery date. Took less than 2 weeks for insurance approval and my surgeon's office did all the paperwork for that.

[ReneBean 3]

You can always appeal based on your co-morbidities... Write out a detailed history of your work with weight watchers and those other supervised programs - find any old documentation - a canceled check, or anything. High blood pressure and high cholesterol are dangerous stuff. You can just tell them that if you croak before the 12 mos is up, your relatives will sue the *&*p out of them and win.

I hate BC/BS too. We know what BS stands for, right? Anyway, If you really do HAVE a history of supervised weight loss attempts and a history of being morbidly obese, you can fight them. Check out the sticky thread in the insurance section - there are some research studies there that you can quote in your appeal.

[Mermaid 0]

Wendiss,

Sorry to tell you this, but I went through the same thing with my insurance company. I met all of their demands. I had done over a year of a medically supervised diet. They kept coming back with more demands that I was able to meet - like asking for cardiac clearance and I had already had a stress echocardiogram I was able to give them. The contineud to deny coverage saying it wasn't medicaly necessary. I had letters from my doctors asking for coverage and everything. After fighting them for 10 months, I just had the surgery a week ago and paid for it myself.

Had I ever known it would take so long to fight the insurance company, I would have just borrowed the money and had the surgery months ago. I would certainly be further along in my weight loss. What do we pay for insurance for? I had so many reasons for them to cover the surgery and still they refused. In the long run, I just had to decide that I was worth spending the money on.

Good luck.

[patty103 0]

which insurance did you have. that is what I heard Cigna pulls. I have bcbs of tn and cigna. I waited a year cause at first I only had cigna and was told that they would deny it. well they kept asking for all the medically supervised. Bcbs after losing paper a few times then denying me cause of the psych eval, which was scheduled finally approved me 3 months after my first visit with the surgeon. but I called them or emailed the atleast 2times a week.. never give up..........

[Dragen_Fyre 0]

Hello all,

This might actually come in handy for some. I decided if I couldn't beat 'em, I'd join 'em. I got a job at Anthem BCBS of Maine.

Anyhow, for anyone having problems, take a look at your certificate of coverage (CoC). That would be the documentation you got when you signed your benefit papers.

It will say whether or not the surgery is covered and any and all exclusions. If your CoC does not mention that you need 12 months of physician managed documentation, you can appeal on that alone. If it does not ask for any other testing or subject to testing limits or approval then you don't have to do it and you can scream bloody murder.

Trust me, they will drag their heels until you scream loud enough to get their attention. Go back and look at your CoC.

Erin

[kat72 0]

Wendy, I am so sorry that you are going through such an ordeal. As far as how long it takes and the pre-requisites, I believe it is different for everyone. I was told (by doctors as well as others) that I would have to wait at least 6 months before a request for authorization would even be submitted. Well, that, fortunately, turned out to be untrue in my case. I started the whole process on August 8th, and I was approved for the band two days after my surgeon submitted a request for authorization. I will be having my surgery on the 7th of November. i was willing to tough it out and wait for 6 months, but it turned out that I only had to wait 3 months instead. Hang in there and keep fighting, because you never know when things might turn around for the best.

[ladysplenda 1]

Talk To A Manager. I Did Was Approved One Week Later. Bcbs

[dcox20 0]

I was the same as Molly Molly - from info meeting to surgery in 1 month - about 2 weeks waiting for insurance - no proof of prior supervised weight loss attempts necessary. Doctor handled it all... FWIW I am in Sacto CA and have Western Health Advantage. I believe my surgery cost about $20k before any follow-up - I paid 2 $20 copays for the whole thing... best choice I ever made for 40 bucks.

[NJChick 3]

You have to ride their butts right untill the end. They approved me the friday before my monday surgery UGGG!

You need to have mega documentation on your WL efforts. Record and write down everything you can think of.

Call them (Insurance Co) 2 - 3 times a week.

Make sure your doctors office sent in what they said. Mine was lax on it.

Get a fax # if you need it.

Talk to managers, not reps.

WRITE down every time you called, the time and who you spoke to. Document every word. It REALLY helps.

You have to be on top of them every step of the way.

From beginning of band process to surgery it took me 3 months

[rpaniagua77 0]

I had to fill out a questionaire when I had my first visit with the Dr. Watson the lap band surgeon. I had to provide details about medically supervised diets. I had tried weight watchers,Atkins, slim fast, the grapefruit diet,and even joined a gym, my primary care physician also provided a letter in which he had prescribed adapex, meridia and I had not been successful in losing the weight. I was really surprised that by the August I had received an approval for the surgery and a scheduled date in October. Come to find out later in August that I was pregnant and had to cancel my surgery. Well I had the baby in March of 2005 and in June started submitting paper work again for surgery. I had my visit again in June of 2005 with the same Dr. only this time it took longer than the first. The billing person at the Dr's office kept saying they were not receiving the information and the insurance kept saying they had sent it. After numerous phone calls to the insurance company and leaving messages with case workers I finally got a call back for a supervisor. She was an angel and faxed the approval letter to me. I faxed it to the Dr. and due to another person cancelling. I will be having surgery on Nov 7th. I am so excited. But I tell you what I thought this was never going to happen. It took so long but I didn't give up. I tell you what those people were tired of me but I didn't care. I finally got what I needed but it was a struggle. Don't give up and try to start keeping a journal of your weight loss attempts. That can be supplied as proof also.

[Mermaid 0]

Maybe I wasn't persistent enough. I had my doctor submit and resubmit documentation. The insurance company would say they didn't have part of the information and they wouldn't accept you just sending in the part they were missing, they made you resubmit everything again. It was ridiculous. I even reported them to the Kansas Insurance Commissioner as I believed they were denying my medically necessary treatment and that went nowhere. I was denied 3 times, was granted a peer to peer review with my doctor and the insurance doctor which, of course went nowhere. This had drug on since January and I was tired of the game. I just finally had the surgery and paid for it myself.

I hope you have better luck with your insurance. I am amazed by some of the stories here and how easy it was for some people.

[Wendiss 0]

I want to thank all of you for your replies to my post. I am amazed at how all over the board your replies are. Seems some you got approved w/o any documentation or trouble at all, while others almost had to sign away their first born just to get a hello from the insurance company. Obviously depends on your doc’s efforts to help you and the state you live in. I am almost certain BCBS of Mich., just recently started covering WLS, so I guess they are going to make anyone who tries to get approval jump though all the hoops.

GET THIS. When I called my insurance company and the customer service rep started telling me EVERYTHING I was going to have to need and do I immediately started to get a sinking feeling that I was going to be on my own with this one. After listening to the very nice, but not very generous CSR basically tell me it was going to take a miracle for BCBS to cover this for me I decided to ask her a question. I asked her if I paid for this on my own would they cover any treatment necessary if there were a complication with the surgery? I was stunned when she quickly told me "of course we will cover any treatment necessary related to any complications from the surgery. COME ON….BCBS has willingly covered and will continue to cover YEARS of medical treatment necessary due to my obesity: prescriptions, tests, arthritis medications, knee surgeries, and even treatment necessary if there are complications with the band surgery, but they do whatever they have to do to not cover the band surgery itself.

Looks more and more like I am going to be paying for this on my own. I am a stress eater and the very thought of battling the insurance company makes me want to order an extra large round pepperoni pizza and eat the whole thing by myself. I just can not handle the thought of doing everything BCBS asks me to do, it taking months to get all their ducks in a row, then having them ask me over and over again for something more. I have done years of weight loss programs, but I really do not have any documentation to give other than the last medically supervised program that I left six months ago. After four months of nothing but liquids, minimal weight loss, and hundreds of dollars I was done. You all know how though this battle is already. I have been fighting and losing my battle with weight for so long I really do not think I have it in me to fight the insurance company and my weight at the same time. I figure why wait months just to still not be approved. Every day I wait is a day I don’t lose any weight.

Again, thank you all for your replies. Regardless of how my band gets paid for it helps to know there are others out there just like me who I can talk to and turn to for support.

[Mermaid 0]

Wendiss,

I understand completely what you are saying. I was given a huge list of the insurance company's demands and could meet all of them except the psych evaluation which I had to pay $250 myself to have done. I had completed 1 year of a medically supervised diet - 1/2 year of liquids and 1/2 year of refeeding. I had already had a cardiac evaluation with a stress echocardiogram. How many people can meet just 2 demands. I thought I would get approved easily. After waiting a few months, then I kept thinking I hate to pay now, I'm sure they will approve it any day. Well, this strung out for months. Records were faxed and refaxed to the insurance company. I wish I had just paid for it myself back at the beginning of the year and I would have been much further along in my weight loss.

After what I went through, I have been amazed at how easy the insurance approval has been for some people. I went through 9 months of stress and fighting and finally gave up - which is what I think the insurance company wants.

Good luck to others in their Quest for approval!

[sarcar 0]

Wendiss,

It is frustrating and time consuming to the vast amount of those that want to have insurance pay for it. It took me seven months and they made me jump through hoops. But the big thing to keep pushing and keep communicating and just do everything they asked. I researched over a year before I decided that I wanted to do this and exactly which of the gastric surgeries I wanted to do. So insurance took seven months and then twelve months prior for research. But the main thing is don't give up.....I won on my first appeal.