Dr's office denied me

[getitgirl 0]

Okay I have tricare prime. My primary care doc referred me for lapband I have a bmi of 35.9 weight of 198 and I am 5.2. I have high blood pressure and prediabetic due to weight. I am not 100 lbs over weight but by surgeon's nurse said I don't qualify under tricare with their strict requirements. Get this I called tricare and they don't have any paperwork on me from this surgeon. In other words they don't even want to put the paperwork in to tricare wtf. I am at my end and I don't know what to do now.

[crecia1975 4]

Okay I have tricare prime. My primary care doc referred me for LAP-BAND®®®® I have a bmi of 35.9 weight of 198 and I am 5.2. I have high blood pressure and prediabetic due to weight. I am not 100 lbs over weight but by surgeon's nurse said I don't qualify under tricare with their strict requirements. Get this I called tricare and they don't have any paperwork on me from this surgeon. In other words they don't even want to put the paperwork in to tricare wtf. I am at my end and I don't know what to do now.

I know all insurance is different, but my surgeon's office found out all of my insurance requirements before submitting a thing. They contacted Cigna and got all of the requirements before I even had my first visit. That way I wouldn't be wasting my time for nothing.

Did you ask Tricare what the requirements are when you called? That might help.

[kittykat56 0]

I agree with Lacrecia. Most Dr's offices call to get the requirements for specific insurance plans BEFORE they submit any paperwork. Some insurances just flat out won't cover. But, if I were you, I would contact my insurance to find EXACTLY what their requirements are, so you know what you're dealing with. If they tell you differently, then contact your Dr's office and inquire about doing paperwork.

I know it's hard dealing with insurance and being denied. I've been denied twice. Good Luck to you!

[BetsyB 9]

It's not a matter of the doctor's office "not wanting" to submit paperwork for you. Your policy spells out precisely what conditions must be met in order for you to qualify for surgery, and if your doctor's insurance specialist has determined that you don't meet the criteria, there simply isn't any point in submitting the paperwork.

Bariatric surgeons have staff very, very skilled at getting procedures covered; if you've been turned down, it's not because they don't want to operate on you---that's what they do, and they like to do it as often as possible. (I am sure they'd be more than happy to take you on as a self-paying patient.)

Insurance contracts are very, very cut-and-dried. If you don't meet their requirements, all the arguing in the world will not change a thing. There's no sense in submitting paperwork when the criteria are not met.

Have you read your insurance contract? There are different levels of coverage, so it's important that you really know what is required according to your specific plan before you get bent out of shape.

If you find that you do, in fact, meet the criteria laid out in your policy, then it would be very reasonable to ask the doctor to reconsider---or to find another doctor whose staff competence you are more comfortable with.

If you do not meet the criteria, the people to negotiate with are those who make benefits decisions for you. I don't know much about how the military works, but in the civilian world, this would usually mean appealing to the people in Human Resources. Making a good argument for increased coverage for bariatric surgery (reduction of comorbidities leads to less loss of time from work, fewer doctor visits, fewer prescriptions, and so on) can often result in policy changes.

And policy changes are what is needed if you don't meet the criteria---because nothing else, short of paying out of pocket, will do the trick.

Good luck! I hope you find that you are, indeed, covered after all. Get your hands on that policy to find out

[maxi2010 0]

Hi Getitgirl.

I agree with all the posts (BetsyB, Kittykat56, & crecia1975).

Your surgeon's office already verbally got a denial so they knew not to submit the paperwork. I have one thing to add. After you find out what are the exact requirements for approval, see if you can make it happen. What do I mean by that? I was denied by my insurance who originally said I needed to have 2 comorbid conditions. They came back and said that I needed a third comorbid condition and showed me that they just changed their policy. I put down that I have symptoms of sleep apnea, (such as loud snoring, waking up my husband, feel tired all the time, etc) but told them that I had never been tested. My insurance came back and said they would cover me if I was tested and proved I had sleep apnea (my insurance had phoned me to tell me that I was denied unless I get this test performed). I got tested, it showed I had a third comorbid disease and my insurance (Empire) turned around and approved me.

My advice to you is to look closely at your medical policy for bariatric surgery. See what diseases they feel count as caused by obesity and see whether or not you have or could have any of these other diseases.

Once you exhaust all insurance options and receive a final denial, then decide if you want to wait until you get sick enough to qualify. If your answer is that you would rather have the LAP-BAND®®®®®® surgery now while you are still healthy, you will have to pay out of pocket. There are a few options for self-pay patients (you can either have your surgery in the US by a US surgeon or have your surgery in Mexico by a Mexican doctor). The difference in price between these two options is significant. If you choose an American doctor, most US doctors will work with you and let you pay off your surgery over time. Some will do this at no or low interest rates. If you decide to go to Mexico, get opinions from some of the LBT members who went that route and appear to be happy with the results.

If you search this forum you will see that most banders think they waited too long to have the LAP-BAND®®®®®®®®® surgery. I'm one who agrees wholehearted with this - I think I should have done this LAP-BAND®®®®®® surgery years ago.

Although I am a new bander (I only got the band on 9/17/10), I can say that the band is changing my life for the better. I have lost 18 lbs already. I started off with a BMI of 36.6 and now have a BMI of 33.6. No big deal? Well, my blood pressure is now on the low side of normal and my usual hypertensive drug (Cozaar) dose was just reduced in half (from 50mg to 25 mg OD) by my doctor. She thinks I will be off cozaar altogether within 6 -12 months. Thus, I'm already feeling the positive affects of the band. She is hopeful that I will be off my cholesterol reducing drug (simvastin) within 1 -2 years. I'm starting to feel much healthier and can walk further without getting out of breath.

What I notice is that I now feel full eating small amounts of food. I have no desire to eat more. I'm also more mindful of what I put in my mouth. The band really does work.

Good luck with your insurance approval. Think seriously about having the band either way. Your health depends on it.

Edited September 29, 2010 by maxi2010
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