insurance question for someone in the know

chinatrain99 · March 22, 2006

I have Health Alliance which is based out of Champaign. That is also where Carl Clinic is where DR Roscheib (spelling) from Clinton does a lot of surgeries. He's recently been doing the band. As yet, my insurance doesn't cover the band and I wonder if it ever will. I wonder if the insurance company is working with Carl to determine the success of the band. I know it's cheaper, if it works as well, why isn't the insurance companies jumping on it?

Alexandra · March 22, 2006

I know it's cheaper, if it works as well, why isn't the insurance companies jumping on it?

It takes a lot of evidence to convince insurers that something new is preferable over something established. Even though this surgery is cheaper, the case can be made that it's not as "reliable" in terms of helping MO patients take the weight off.

Also a factor, I'm certain, is the industry's fear that a lot MORE people would go for bariatric surgery if banding were more widely available. The seriousness of RNY probably keeps many, many medically qualified candidates away. It sure kept me away! So carriers would have to be shelling out untold amounts of money to treat people who currently cost them nothing.

As for the future costs of allowing patients to remain morbidly obese, we'd think carriers would care about that, right? But they don't. Any given individual is statistically likely to be someone else's problem in the longer term.

All of this will come home to roost as the population ages and grows fatter. I personally believe that banding will in time become the WLS of choice, and people will have to prove immediate need to qualify for RNY. But this will be slow in coming, like all medical revolutions within the insurance industry.

chinatrain99 · March 24, 2006

Thanks Alex...that's what I've been thinking. I'm a little surprised nobody else commented. I'm sure that I'm not the only one checking out this site that isn't banded. I don't think I'm alone in "waiting to see what insurance" does either.

zacsmom · March 30, 2006

Great question , if you ask me the pharmaceutical companies NEED us to be taking blood pressure meds , cholesteral meds , Water pills from the bp meds , etc , etc , etc ,they could very possibly be working together , I know I sound paranoid but at this point I can sure be certain that it's not my well being that the insurance company is concerned with !

Lisa Jarva-pre-op

waiting impatiently to be banded , having second thoughts , having a sleep study with cpap this Sat , diagnosed with apnea. I've been told I'll have to go through a "medically managed weight loss program" before surgery will be approved due to the Mental health portion of the insurance requiring it for the tests before surgery....grrrrrrrrrrrrrrrrrrrrrrrrrrrr

Any thought or info on this is always greatly appreciated.

chinatrain99 · March 31, 2006

I understand the Dr supervised diets...been on one for years. I'm 390+ lb, 5' 7" and 40 years old. I was a week away from the bypass and backed out because I could never see long-term results...it's much simpler to die from obesity than to be operated on and stress your body with malnutrition...maybe a bad attitude about it, but I've heard of lots of problems. The band was what I wanted even back then. I have borderline diabetes, high blood pressure, and severe sleep apnea. My goal isn't that lofty...I'd like to be below 275. I see a lot of people with the band that do very well and some that it looks like wasted their money. If you don't change your lifestyle and what you eat, it won't work. However, if you do change your lifestyle and what you eat, you should lose weight. That makes me hesitate from doing it. I don't think a band will work for someone who eats ding-dongs. May not be able to eat as many ding-dongs, but they still won't get good results. Right now, I'm doing the excersise thing. I do the eliptical for 20+ minutes a day (2500 steps because my short fat legs move no faster), lift 3 days a week, and try to do the bike 4 miles 5 times a week. I've stepped it up quite a bit from just lifting..I wasn't losing anything. Dr told me more cardio so I bought the bike. In the last week, I started the eliptical...I'm planning on sweating it off. Did 35 minutes yesterday morning and went to bed at 7:30 last night! I'm trying to eat better...more meats and fruits. However, I eat like a horse. I think the band would help me with that a lot. I think if my insurance would cover it, they'd say that my BMI was too high.

JMO · March 31, 2006

Medicare just approved the lapband in January. Usually other private ins. companies follow with in a year or so.. Medicare sets the bar, the others try to stay with them.. ( thats not saying some ins. cover things that medicare doesn't but they usually follow their lead)

Hang in the, I was in the same boat with Bcbs. our employer had it wrote out of the policy but withmuch fuss from many employees we now have it as a option. I am just starting the process I have my first visit next week.

chinatrain99 · March 31, 2006

Good for you. However, I think with a bmi of close to 60, I'll be in a fight with my company for coverage. I think they're putting too much emphasis on the BMI and not the individual...Oh well, cross that Water when I get there.