Denied...what should I do?

[kerri76 0]

I got the call from the insurance company today that I was denied. I meet the criteria for the insurance to pay for the Lap-Band in all areas except one. I need hypertension, heart disease or diabetes and I have neither. I am fat (BMI over 50), have high cholesterol and depression. I am only 34 and will eventually get high blood pressure or diabetes if I don;t lose the weight. I told a fellow bander that I was denied and she said that I should go see her surgeon and see if they can get the insurance to approve. Do you think it is worth it? Do you think that maybe I can find a doc that will give me a diagnosis of high BP even if it really isn't? I know that's bad! This sucks, I am soooo disappointed. I was looking forward to starting my weight loss journey and actually being successful. Any suggestions would be greatly appreciated!

[Aquarius12459 0]

First, do you have a surgeon picked out? If so, then I would go back to him and see what can be done or get another opinion from a different surgeon. Have you been on other supervised diets such as Jennie Craig, Weight Watchers and have failed? I had either heard or read something about if you have been on something of this nature and you didn't lose or didn't lose as expected and it was documented, that could be submitted to the insurance company for plea for them cover the surgery. I believe it was for a 6 month period. Maybe you could try something of this nature for the 6 months and then go back to your doctor? Good luck to you.

[jre1974 0]

I had a BMI of 64 and High BP, diabetes, arthritis, blah, blah, blah.....and my insurance still told me no...I finally decided to self-pay. I was able to finance the surgery and the payments are manageable..I used a company called CareCredit to finance it for me...maybe thats an option.

[kerri76 0]

JRE1974-How much is the surgery? It's just silly that I need one mpre illness and then they will pay it. I am so depressed about it! I need to be physically unable to overeat! So damn depressed now!

[BetsyB 9]

It usually boils down to what is written in your specific insurance contract. Most seem to require comorbidities only for BMI less than 40, but your employer may have had the contract written differently (to save money---which is stupid, because obesity costs SO much more!).

You can try to find a doctor who will identify comorbidities that don't really exist---but really, I'd approach it differently. (No matter how much you want something, fraud is fraud.) You may even find that you DO have comorbidities that "count" ---did you have sleep studies or see a pulmonologist?

I'd approach HR to tackle it from their end. When renewing policies, they have the power to effect changes.

In the meantime, it would be a really good idea to start the weight loss journey you had planned anyway. Your BMI is high enough that you will NOT get ruled out for approval if you lose.

I know it's very hard without restriction (just ask any of us who haven't yet achieved it!)....but it can be done. You can start NOW to adopt the habits you will require once banded. It's just healthier--emotionally and physically--than adopting the fatalistic attitude that gain (and further development of comorbidities) is inevitable.

Good luck!

[jre1974 0]

I financed it myself and it cost me $16,500...which sounds like a lot, but that covers everything...the surgery, the hospital stay, all the follow-ups and fills for one year...

Really if you think about how much you normally pay for eating out every day, the payments will be fairly comparable. I used to spend $300-350 a month on eating out and now, I don't eat out at all...So that alone has covered the monthly payments...I don't know the exact amount because my wife writes out all the bills...but i know its 2-something a month...

besides, I think that if you fork out the money yourself, and are making that payment every month, you're gonna think twice about cheating and will take it more seriously than if the insurance paid for the entire thing...

I see people posting almost everyday about how they are cheating here and there and some of the things they say they are eating just makes me shake my head and think, "you're doomed..." I paid for this surgery out of my own pocket, so I feel like I will take it more seriously and work harder during those bad times where all you want to do is cheat... Just my opinion. :frown:

Its something to think about..Good luck with whatever you decide.

[Froggie D 1]

There are lots of other comorbidities like reflux, apnea, joint pain, severe stress incontinence - maybe you have not looked deep enough. Find a doc who will work with you.

Most insurances also have an appeal process you should ask about. I think sometimes they are testing your commitment by denying first. Tey again!

[ThreeDaysLong 0]

My doctors office went to bat for me...they dealt with the insurance 100%...find a GOOD surgeon and have them do all the leg work...you can also have the doctor write a letter to the insurance to dispute the surgery denial...my office would do that three times before heading down a different road to get it approved...keep pushing it...it will be WELL worth it...