Can someone help me?

[peacequeen 434]

I'm just starting this whole process. I am sheduled for the seminar on Jan. 4th. When I called my insurance company to ask if lapband was covered the lady asked me if this was just something I wanted to have done or were there doctors recommending it. I felt like it was a "trap" question. She said they would require a doctors recorded medical records stating I was morbidly obese and have had this problem for up to 5 years and the doctor who is recommending that I have the surgery. My neurologist is the one who suggested the lapband surgery after I told her I was dieting again and not doing so well as usual..it was casual conversation,,she's a neuro.lol. Do I need to go to my primary care doctor and get recommended for this surgery or do I go through the surgeon that will be performing the surgery that I'll be meeting at the seminar? Do I ask a doctor to recommend it for me or tell them I want it.. I'm a little confused on what I need to do, I'm afraid to say I want the surgery but who here would say they don't want it? I think its something that is necessary in my case.

[tntbelt 1]

At my first intake appt they went over everything that would be needed for surgery which included a referral form for my primary care physician to fill out stating they recommended the surgery.

[JerseyGirl80 12]

Hi PeaceQueen,

I was in your shoes, my first step was going to a seminar and making an appointment with the surgeon. I didn't know him, I wasn't referred to him by another doctor, it wasn't suggested to me by my doctor to have this surgery, I just kinda dove right in. My boyfriends mom and sister happened you be patients of his so I figured I'd check it out. I knew I met the requirements, size wise and my family history, to have this done. It was just a matter of finding out if I had any co-morbidities and if my insurance would cover. If you find a great surgeon, like I did, the team at his office will help you do what you need to do every step of the way. I met with him and he asked me specific questions and I was prescribed blood work, a chest x-ray, an EKG, and a sleep apnea test on my first visit with him.

Every insurance is different, some require some crazy things and make you jump through all sorts of hoops or go on 6 month diets, some are not so difficult as long as you have some record of you being overweight for X amount of years and/or a co-morbidity. It already sounds like your insurance is open to this surgery, your Docs office will know what to do to get you approved. Don't get overwhelmed or discouraged, like I said find a great Doc who has a wonderful staff and they you guide you along your journey. Hope this helps. Good luck!

[~*~Rachel~*~ 2]

I'm just starting this whole process. I am sheduled for the seminar on Jan. 4th. When I called my insurance company to ask if lapband was covered the lady asked me if this was just something I wanted to have done or were there doctors recommending it. I felt like it was a "trap" question. She said they would require a doctors recorded medical records stating I was morbidly obese and have had this problem for up to 5 years and the doctor who is recommending that I have the surgery. My neurologist is the one who suggested the lapband surgery after I told her I was dieting again and not doing so well as usual..it was casual conversation,,she's a neuro.lol. Do I need to go to my primary care doctor and get recommended for this surgery or do I go through the surgeon that will be performing the surgery that I'll be meeting at the seminar? Do I ask a doctor to recommend it for me or tell them I want it.. I'm a little confused on what I need to do, I'm afraid to say I want the surgery but who here would say they don't want it? I think its something that is necessary in my case.

My neurosurgeon is actually who started my process. I have three herniated disc in my back and he recommended lap band to loose weight before I gave into back surgery. He set me up with the seminar and appointment for the surgery and wrote me a letter of recommendation stating he thought the weight loss surgery was what I needed to try giving my age. Call your neurosurgeon and ask for the letter all they can say is no...

[allygator 1]

Victoria

I contacted the surgeon directly too. I have learned over the years that I have to be my own advocate and if you don't ask they usually wont tell..at least with my PCP!! I was starting to think I had done the whole thing backwardds but the surgical group had me fill out a ton of paperwork and said they will contact my insurance. I was thinking maybe I should go ahead and make an appt with my PCP just to have that conversation in case I need a referral but I think I'll wait until I hear from the surgeon. If ins covers it it will pay 90% after the 500 deductible, which I have in a health care spending account, so I am thinking Ill end up paying another 500 or so out of pocket...which I DONT have but I am willing to find a way to make it happen. I am lucky I have such good coverage for now. I will be changing jobs in a year and who knows what kind of coverage I will have then, possible none since I will be interning for awhile, so I decided to take the plunge after "thinking about it" for about a year now.

[JerseyGirl80 12]

Victoria

I contacted the surgeon directly too. I have learned over the years that I have to be my own advocate and if you don't ask they usually wont tell..at least with my PCP!! I was starting to think I had done the whole thing backwardds but the surgical group had me fill out a ton of paperwork and said they will contact my insurance. I was thinking maybe I should go ahead and make an appt with my PCP just to have that conversation in case I need a referral but I think I'll wait until I hear from the surgeon. If ins covers it it will pay 90% after the 500 deductible, which I have in a health care spending account, so I am thinking Ill end up paying another 500 or so out of pocket...which I DONT have but I am willing to find a way to make it happen. I am lucky I have such good coverage for now. I will be changing jobs in a year and who knows what kind of coverage I will have then, possible none since I will be interning for awhile, so I decided to take the plunge after "thinking about it" for about a year now.

If you have good insurance and you are physically and emotionally ready to make this step, do it, don't hesitate, you don't know what could happen. I was very close to not having mine because of the insurance change at my job. My Doc doesn't take the new insurance which was devastating news and I was on edge for days waiting to hear back from the Doc to confirm my clearance for rushed surgery. Luckily the office staff was amazing and was able to get me a surgery date right away. Otherwise, I would have had to start the process all over again with another surgeon, more tests, more dieting blah blah blah. And from what I understand the requirements are harder to meet for BCBS (my new one) than Aetna (my old one).

[Kat817 19]

If insurance requires a Dr's statement saying the surgery is recommended, they don't usually have a care who or what Dr. recommends it as long as it is not the surgeon himself/herself, or anyone affiliated with the office who will financially profit by you having the surgery. So your Neuro could do that no problem. You will still likely need to have your PCP in the loop, as you will need copies from your file of your weight over the last 5 years it sounds like. Your PCP can also indicate any other issues you may have that are weight related, if you do not have the documented 5 years. If you have to contact an old Dr. for the copy of a page from your chart, showing your weight 5 years ago, expect to pay up to $6.00 a page---I have paid $2.00 a page generally. Your PCP, can also provide records of high blood pressure, or high blood sugar readings, or high cholesterol, previous complaints of back pain, or other joint pain, any symptoms of sleep apnea that might be weight related, possible PCOS, even depression.....all of them can help you qualify for surgery if your insurance requires co morbidities.

Find out EXACTLY what your insurance requires and follow it to the letter! They are all looking not to have to pay for anything! Find out if you have a 6 month lead in----many do. Back when I was banded our particular BCBS plan, had a 12 month physician supervised weight loss requirement, as well as a monthly visit with a dietician. I live in the boonies, there was no licensed dietician! So I had to go through the insurance to get them to allow my PCP to act in the dietician role---so I had to go see him 2 times a month---for a year. Co pays on each visit. Once he just weighed me, and documented it, with me telling him what my exercise had been, and the second he counselled me in nutrition (I could have taught him a thing or 2, even if he was skin and bones!!!!). Well I did this for 10 months, 10 and a half technically, I had just come from the 11th visit with him in the supervisory mode, and I was in a car accident---not my fault---I was hit from behind and pushed into a light pole, pinning my knee between the dash, my door and the pole. I ended up in the hospital having knee surgery. When I went in to my next appointment, the office manager ask me into her office to explain to me, I would have to start my 12 month pre op work up again, as the visits have to be in 12 CONSECUTIVE months, and due to my surgery I missed the 11th dietician one! I was going to have to start over!

I wrote insurance, and called insurance, did it all, they turned me down 3 times. They would pay for it, as soon as I did 12 months consecutive.

First thing I did was change Dr.'s-----these people knew me, my DD worked for them, and it was them that reported me "not showing" for my nutrition appointment. THEY could have kept it on track, he come to see me in the hospital---but not as a nutritionist!

In the end.......I received a settlement from my knee, took the money to Mexico and had surgery, and by the time my next year would have rolled around, I was down 75 pounds!!!

Point to this long story-----find out what EXACTLY the requirements are----have them mailed to you----take names of who you speak to at the insurance company---document times and dates you call and what you were told-----and follow the guidelines to the letter if you want insurance to pay!

Also not to discourage you, but much of band surgery takes place AFTER the original surgery. Fills can run up to $600.00 I am told! Think about whether if you are going to be without insurance you can afford the aftercare.

Good Luck to you!!!

[peacequeen 434]

Kat, I had to take steroids too, I was already overweight,,,then an extra 57 lbs later and I'm checking out lapband. It threw me into an all time high and I remember the mood swings..oh how I don't miss prednisone.lol I have dropped 16 pounds but I'm still at 261 and have struggled so much since. I don't really have a problem getting the records of my weight history, that shouldn't be a problem. I'm more than 100 pounds overweight now, I also qualify due to co morbidities but I have myasthenia gravis, it's a rare autoimmune disease, I don't know if it will be a hurdle for me or not.

I am disabled, I have UHC right now and will be getting medicare in April, should I wait and have the secondary or does medicare make you jump through hoops too? I'd almost rather pay some out of pocket than put up with the insurance company headaches.

Thank you all very much for your advice and comments. I think I need to get a journal started.lol It's kind of nerve racking to think about it all. I think writing everything down and keeping good records is a very good idea..thanks again!