New Here, In The Early Stages Of "thinking About It"

[Sphinx 22]

I am excited but also cautious. It's unknown whether or not my insurance will accept my many dx as comorbidities. I'm having loads of lab work in case anything else shows up. I'm calling the surgeons office tomorrow. From what I can tell it looks like the next seminar or whatever it's called is at the end of next month. I hate waiting! I'll have to do the physician monitored diet, from what I can tell with my insurance if I do a comprehensive program as part of surgery preparation I only have to do 3 months not 6.

The only other thing is that even though my BMI is 38 now, it's dipped below 35 a bit and I'm not sure what insurance will think of that. To me it just shows what a yoyo I've been. But we will see how it all goes and I am thinking positively!

Of course saying all this right after I polished off a too large meal. Well, I have to work on that one. I get so hungry at work! (At work now). How are you doing?

[Christy.Lynn 10]

I think comorbidities are pretty straight-forward. My dad played the insurance game to get a gastric sleeve and he didn't have to do hardly anything because he had a diagnosis of sleep apnea, and plenty of others to support his need for the surgery. Waiting if very frustrating! But if you play their game and jump through their hoops, it will be very worth it! It can be a lengthy process, but just try to keep patient.

And maybe practice eating less and slower? I am shocked at how eating so slowly and chewing so thoroughly can be so satisfying. I eat much smaller portions, but I truly enjoy my food and find that by eating so slow, I often get distracted by something else before I'm done! I feel like I'm eating like a skinny person and it's oddly enjoyable

[Sphinx 22]

Well turns out it's all for nothing. I called the surgeons office and I can't even get an appointment because I need to have degenerative arthritis (RA doesn't count), Hypertension, Diabetes or sleep apnea and be on daily medication for the above. She said my insurance wouldn't make exceptions for my other diagnoses. I asked about private pay and she said that the same guidelienes apply. I knew that these were the accepted comorbidities, but was hoping to start the process and try to work with my insurance based on my RA and whatnot (reflux, etc). I know that weighing less would help my RA pain but I guess it doesn't matter. Even if my labs come up with diabetes I have to be on daily meds, not diet controlled.

I am really bummed.

Not that I'd purposely try to gain weight but if I keep gaining as fast as I have been I may just reach 40. But I hope not.

[Sphinx 22]

Oh and I just called my insurance and they said they may or may not pay but they have to get something from the doc for per certification but

[Sphinx 22]

But if the doc won't see me how can that happen? Argh!

[Christy.Lynn 10]

Ok, I'm just recapping: so your bmi is between 35-40 so you have to have an exiting co-morbidity that you're treated for daily. The surgeon's office won't see you because you don't meet the co-morbidity requirement. Your insurance says they may/may not pay but they need something from the Dr. Which dr do they need something from? Your primary care or the surgeon? Because your primary Dr could do a recommendation/referral for surgery and then that might get you an appt with the surgeon. Or, you could pay out of pocket for a consultation and try to get something from the surgeon that would cause insurance to authorize the surgery.

If I were in this situation, I would first call the surgeon's office and ask to speak with the insurance coordinator person. Explain your situation and that you don't know yet if insurance will cover you, and ask them how they recommend you find out (whether that be seeing the surgeon and getting a surgeon recommendation or something). Tell them you don't have textbook co-morbidities, but that you have health issues that would greatly benefit from surgery.

If the surgeon's office won't talk to you, clarify from insurance (get the person's name and direct extension if available) exactly what note/something they need and from a primary care or a surgeon? Then see if you can call the surgeon and tell insurance said if I get _____ from your office, they will submit my case for review.

[Sphinx 22]

Thank you for some much needed clarity. I guess I was just so confident that going shot down before having a chance really killed me. I believe the person at my insurance company was speaking of the surgeon as they need to send over a pre certification not a referral (I don't require a referral for any specialists with my insurance. So I will try to call the surgeon again and see I their insurance coordinator will help. As it stands I can't even register for a seminar!

I also had my labs drawn today and once the results are in plan to see if my primary doc will refer me for a sleep study and x rays of my knees and hips. Haven't ha my hips done in a couple years and never had my knees done (never had knee pain until the past few months.....not surprisingly when my weight started creeping up again haha). So maybe something will turn up there. Well I have a phone call or two to make then off to the gym! Gotta keep working at it!

[Sphinx 22]

Oy. Called the surgeon's office. The woman who answers the phone strikes me as a gatekeeper who doesn't necessarily know the score. She didn't even know if they had an insurance coordinator. She did "go and check" and transfer me to someone, but that person didn't answer. I left a message but didn't hear back. Will have to try again tomorrow.

[Christy.Lynn 10]

Can I have their number? I don't think I'm as polite as you and I could get some answers just kidding.

Maybe try a different surgeon? Is that an option? You could call the insurance company and see if they have preferred surgeons?

[stickks 19]

Hi, I found this website, as I have been thinking about looking into getting lapband surgery done. I have had weight problems for a long time, tried many diets and nothing seems to work. I have cronic high blood pressure, sleep apnea as well. I dont have diabetes at this time, but my family has a history of it. I have lower back problems, joint problems, etc. My weight is 258 lbs right now. I am male, 6ft2. My bmi is around 33.8. I have Aetna insurance. Looks like they might cover it for me according to their website, with some conditions. Anyone have any insight into this?

[Sphinx 22]

My weight is 258 lbs right now. I am male, 6ft2. My bmi is around 33.8. I have Aetna insurance. Looks like they might cover it for me according to their website, with some conditions. Anyone have any insight into this?

I don't think insurance will cover if your BMI is less than 35, even with comorbidities. Don't know about private pay though!

BTW, try posting this as a separate new topic, you'd likely get more responses, since this is tacked on the end of my post it might not get seen

[Sphinx 22]

Can I have their number? I don't think I'm as polite as you and I could get some answers just kidding.

Maybe try a different surgeon? Is that an option? You could call the insurance company and see if they have preferred surgeons?

LOL! Yeah, I am pretty polite......not the most assertive person! When I try to be more direct it is often because I'm so mad, but when I lose my temper I sometimes start to cry which never works haha!

Anyhoo.......

The insurance coordinator called me back today. I swear I didn't do it on purpose, but when she asked my height and weight she said "Well, you're BMI is 40 so you should be ok". I'm like, ummmmm, I thought it wasn't? She said it was 39.8 but that would count as being 40. I know it's just a hair over 38 and I realized I must have told her something wrong, but decided to let it slide. So after we talked I figured out what I must have told her to get a result of 38.8 and called to make an appointment, and told her that. I know that's bad, but I just wanted to get in the door. So I am registered for a class September 27th. It will probably be a waste of time but ya never know.

[Sphinx 22]

I called my PCP today to see about getting eval for a sleep study (waiting for a call back, might end up being tomorrow). My labs all came back normal re: other comorbidities and I am not hypertensive.