seriously considering getting the lapband

[babyk 1]

o ok...i see. well i'll call and hope for the best :thumbup: thanks for all the great advice

[ardelia 41]

I would call the insurance company and ask them if they cover it and what their requirements are. Also ask what your copays are for the procedure and office visits. You might even be able to read up on it online. My company's information is right there. Find out if with the PPO you need a PCP referral.

Find out what BMI they require and how long you have had to be there. If they require a BMI of 40 with no co-morbids but that you had to be 40 or over for 5 years, there is no point in purposely gaining to qualify. Find out what their co-morbidities are to see if you have any of them. Then with a BMI less than 40, you know you are OK.

Requirements are similar with insurance companies, but not always the same. Some have implemented a requirement of a certain BMI for 5 years, to disallow the purposeful gain of weight to quailify for surgery.

You can also ask for doctors and hospitals in the network.

Go to the seminar armed with this information.

If you are denied, your insurance company should have a grievance or appeal process. Cross that bridge if it happens.

With regard to asking what the hoops are to be jumped through, I can tell you my experience today.

I called my insurance company (Keystone Health Plan East) to ask a lot of questions. I found out that LAP-BAND surgery is covered as an inpatient procedure "based on medical need" and that the patient "must meet all criteria." Of course, I asked what those criteria are, but she told me that she is not permitted to give out that information. She also refused to tell me what the insurance code is - not that having it would do me any good. She did tell me that there "are 7 to 10 things" that make up the criteria and that my doctor's office (surgeon) would be able to tell me what they are based on my insurance.

I also found out the following:

• My co-pay would be only $250 (the inpatient co-pay).
  
• All pre-op testing is covered, as would be any procedures afterward that would be medically necessary (e.g. band slippage repair, defective port having to be replaced).
  
• The nutritionist is not covered, per my company's specifications.
  
• All of the paperwork would be submitted to the pre-certification department and that their decision would be mailed to me in 7 to 10 business days.
  
• After approval, I could schedule the surgery based on my surgeon's availability.
  

So...YMMV, but this was my experience. The woman I spoke to was extremely helpful and very patient with my numerous questions. We were on the phone for a good 25 minutes.

Oh, one more thing...When I asked about bariatric surgery, she specifically asked, "What are you considering? LAP-BAND?" I guess they must be getting a lot of folks asking about it? She did not mention the sleeve or GB.

[babyk 1]

wow very helpful. thanks so much.

[Cocoabean 430]

With regard to asking what the hoops are to be jumped through, I can tell you my experience today.

I called my insurance company (Keystone Health Plan East) to ask a lot of questions. I found out that LAP-BAND® surgery is covered as an inpatient procedure "based on medical need" and that the patient "must meet all criteria." Of course, I asked what those criteria are, but she told me that she is not permitted to give out that information. She also refused to tell me what the insurance code is - not that having it would do me any good. She did tell me that there "are 7 to 10 things" that make up the criteria and that my doctor's office (surgeon) would be able to tell me what they are based on my insurance.

I also found out the following:

• My co-pay would be only $250 (the inpatient co-pay).
  
• All pre-op testing is covered, as would be any procedures afterward that would be medically necessary (e.g. band slippage repair, defective port having to be replaced).
  
• The nutritionist is not covered, per my company's specifications.
  
• All of the paperwork would be submitted to the pre-certification department and that their decision would be mailed to me in 7 to 10 business days.
  
• After approval, I could schedule the surgery based on my surgeon's availability.
  

So...YMMV, but this was my experience. The woman I spoke to was extremely helpful and very patient with my numerous questions. We were on the phone for a good 25 minutes.

Oh, one more thing...When I asked about bariatric surgery, she specifically asked, "What are you considering? LAP-BAND®?" I guess they must be getting a lot of folks asking about it? She did not mention the sleeve or GB.

That is interesting they won't tell you what the 7 to 10 things are.

I suppose they don't want you to cheat :thumbup:

I just read my brochure and it says call us for further information on criteria for surgery. The criteria is not limited to what is shown.

It also changed from when I had my surgery to a BMI of 35-40 an one co-morbidity. They also don't list a 6 month medically supervised diet. So it is constantly changing.

As a side note, I haven't seen any insurance companies covering the sleeve procecure yet.

Edited July 12, 2010 by Cocoabean

[ardelia 41]

Yes, I think that it is odd that the insurance company won't tell me that big secret.

No worries...my surgery consult is on Thursday, so I'll ask the office staff then.

[Cannon_d 0]

Hi, I'm new to the site. I am a 29 year old female, over 300 pounds, and can't really remember a time in my life when I wasn't overweight...though I know there must have been when I was a child and SUPER active. I decided to join this site so that I could get lots of information about the procedure (I am pretty sure I am going to have it done if possible) and also for support as I go through the process.

I have my initial consultation scheduled for tomorrow afternoon, and already know that my insurance doesn't cover the surgery...so any suggestions on what to do would be GREATLY appreciated.

My mom and brother work with a lady who had the procedure 2 years ago, she went to Mexico to have it done because it cost a LOT less there, but ran into problems with finding a doctor to do the fills when she got back. They put me in contact with her yesterday and she suggested to me that I start looking at online support sites like this one, so I found lapbandtalk.com.

Any information and suggestions are very welcome, thanks. :grouphug:

[Amaris 0]

@babyk, glad to provide some answers. Hope they helped!

I am not banded yet. In fact, I don't even have a surgery date yet, but I'm hoping for late August or early September. I started by pre-op diet today because I have to do four to six weeks on it, and I didn't want that to be a barrier to getting a surgery date.

Good luck to you! Get in touch if you have any more questions that you think I can answer!

@Cannon_d -- good luck on your journey! I hope things work out for you. My insurance covers mine, so I didn't have to research options, but I do know that there is special medical financing. Your surgeon's office should be able to tell you more about that.