Need a little info.....

[ShellieB73 0]

I'll try to make this brief....

I had Lap band surgery 2.2008...lost about 70 pounds very easily. Had a slip 11.2009....removal 3.2010. My insurance at the time would not pay for a replacement of the band because I was no longer "morbidly obese"....even though I didn't get to goal.

My surgeon talked to me about the sleeve and I have been seriously considering it since November. Also, I have gained back nearly 30 pounds since November.

I am getting new insurance due to a job change May 1st. I am praying that they will cover WLS for me and specifically the sleeve. My problem is that my surgeon does not operate at a "participating facility", so my options are to pay a 40% copay and the non participating facility or find a new surgeon.

Is the 40% figured on the allowable charges or on the billed charges? We all know that insurance doesn't pay the entire billed charges, but usually cash pay patients do unless there is a prompt pay discount or something similar. Has anyone had any of these similar issues? I wish I could find some more concrete literature on the long term success with the sleeve. Specifically, are there any issues with ulcers, strictures etc.

Guess that wasn't real brief, but I'm really feeling desperate due to my weight gain. It is so discouraging and I physically feel lousy!!!!

Thanks....shell

[pnw218 14]

I am sorry to hear about your situation! It must be very frustrating.

I don't know if all insurance is the same - I pay a percentage of allowable charges. Just not sure at the moment if it is before or after the insurance payment is deducted??

Probably the safest route is to call and talk to customer service for your insurance. Not sure if the new insurance can give you much info yet tho??

[Tiffykins 673]

I can't help you on the insurance stuff.

But strictures can happen, but with the sleeves being made with the 32fr-40fr they have seen less strictures. Ulcers can be an issue if you are prone to ulcers pre-op, and but I haven't seen it in any of my research as a long term complication. My surgeon said smoking post op can cause ulcers.

Welcome to the forum, I hope you get some answers on the insurance front. I know how frustrating the band can be. The sleeve is a great tool, and it's night and day vs. the band.

Best wishes.

[MINI-Me 196]

Normally with insurance, if you go to a non-participating hospital, the insurance pays 60% of their allowable for the service. You are responsible for the 40% plus anything between the allowable and the billed amount. It could be a lot or it could be a little.

Once you get your new insurance, find out all you can about the policy and the allowances (the doctor should be able to give you the procedure code and the hospital should be able to give you codes for the operating room, hospital room, etc). Give those codes to your insurance company and they should be able to provide the allowances.

Best of luck.