Just beginning the insurance process - suggestions/help???

July 12, 2004

Hi everyone - I am new to this board and new to this procedure. I went to see my pcp today for a referral to the surgeon which he happily agreed to with no problems. His office indicated that the surgeon (Dr. Scott Cunneen @ Cedars) would put the requests in to my insurance company for approval. I am with Cigna HMO through the Walt Disney Company - After reading so many of the posts here about the problems people have had getting their insurance companies to approve this procedure - I am just hoping that I am not setting myself up for heartache and dissappointment if it ends up being turned down. The "problem" is that my BMI is at about 33.1 - I am 41 years old and 5'2" but have a very very small frame and currently at around 185 lbs. Before I was 35 - I was between 115 and 125 then I just became obese over the past 6 years. I have tried everything, exercise, dieting (millions) pills, everything you can imagine with little or no success. 185 may not seem like a huge amount of weight but given my small frame and all the problems I am having because of the weight (knees, joints, back etc) I feel that I am a good candidate for lap band surgery - so does my pcp. I am worried that given my circumstances, I am going to have issues getting insurance approval and without the approval - I can not afford to have the procedure done. Anyone out there with any advise or information that could assist me would be GREATLY appreciated. Thanks so much - with my fingers and toes crossed

Alexandra · July 13, 2004

Hi Doxiegal,

I have to say that I doubt you'll be successful in this Quest, at least now. Insurance carriers are really not interested in investing money for preventive procedures, which is what banding you would be. At this point you are close enough to a normal weight for conventional methods to make a big difference in your health (or so the thinking would go).

The day may come when the insurance community takes a longer view at health care, and realizes that a healthier society now will save them (and us all) money down the road. But sad to say that day is not yet here.

Just my POV, and I would very much like to be wrong. Good luck!

New Hope · July 13, 2004

Doxiegal, I had the very same problem. Small frame, but I gained much more weight than you did. My husband changed jobs last year & I finally had an insurance co. that covers weight reduction surgery. It still took 8 months after the first denial. Last several years, I had developed several health issues...high blood pressure, asthma, hiatal hernia, arthritis. They've all improved drastically since I finally lost some weight! Self-pay wasn't an option for me. I hope you don't have to get to this point to get help. Best of luck!

Lisa2403 · July 13, 2004

Hi Doxiegal,

You and i have very similar stats. I was 43, 5'2 and weighed 186 when I got my band. My PCP was supportive but my insurance co would not even CONDIDER WLS for me. (and I have Diabetes, high BP and high Cholersterol). I have Cigna HMO in FL.

Also, some US Dr's will not do WLS for anyone with a BMI of <35.(even self-pay)

The reason given to me was that the band was FDA approved for BMI over 40 or over 35 with co-morbidities. Do use it otherwise was out of the FDA approval realm.

I thought about trying to gain another 25 lbs (not too hard!) or even adding heavy clothes, ankle weights etc! but then I didn't want to wait another year or more-so I borrowed against my home equity loan and took off for Mexico!

I have lost 30-35 lbs and have 30 to go. I am very happy with my decision and think it was money well spent.

Good luck, hope you insurance works out for you.

Lisa

DeLarla · July 13, 2004

Lisa, I also took out a loan from the credit union. Then I transferred the balance to a "zero percent interest for one year" credit card. Now I'm working a 2nd job at minimum wage to try to knock down that balance.

What is SO important to understand, is that I would never have had the energy for a 2nd job before my band. I've dropped 40 pounds so I have energy to burn now.

Self paying is worth every penny and pays for itself in 1-2 years. The amount of money I was paying in doctor bills, prescriptions, lost work, food, clothes. I was paying $35.00 for each co-pay plus 20% of my stomach ultra sounds, MRI, EKGs, X-rays, etc. Plus $6.00 for every prescription ... 7 different stomach pills, blood pressure, anxiety, sleeping. I was paying $30.00 a month for my breathing machine for sleep apnea and haven't used it in a week now. Our grocery bill went from $180 each trip to $110. The amount spent on fast foods has almost vanished. I'm finding cheap clothes in sizes off clearance racks, while before I had no option but buying the largest most expensive ones.

So anyone saying they can't self pay probably can. If the credit union refused my loan, I'd have pawned my wedding ring, my TV, my car. I'd have done anything to get the money, cause like I said, the band pays for itself.

However, I have seen a lot of people get their insurance to pay. My best suggestion is to start documenting every single diet, success, failure, etc. I know that some insurance companies require a 6 month log of attempted dieting.

hopeful1 · August 10, 2004

New Hope,

I just received my first denial letter today and I think (hope) what it's saying is the insurance doesn't have all my information and tests. My insurance required a psych eval, nutritionist visit, and some other tests - thyroid, glucose. I had heard they required documentation of 6 months of dieting under a doctor's supervision. I had proof of maybe 3 or 4 mos. at WW. Excess weight is 120 lbs., BMI is 42.5(?). I do have (17 yrs.) hypothyroidism and take synthroid and hope that's not the problem.

But to get to the point - why did it take you eight months to get approved?

Denise