Just starting to explore options...help!!!

[Alexandra 55]

Hi Reberlan,

I'm not sure what you're asking. If you have Aetna as your health insurance, your plan will dictate how you should proceed. For example, if your plan is "gated" (meaning if you need a referral) the place to start is with your primary care doctor. Get a physical and get a diagnosis of morbid obesity in your record, and get a referral to a bariatric surgeon.

If your plan doesn't require you to get referrals, you can go straight to a surgeon in your area who performs the surgery and participates in the Aetna HMO network. Whichever way you get to the surgeon, it's that doctor who will tell you what the presurgery requirements are, and it will be his job to submit the request for surgery precertification.

Good luck!!

[Gigi001 0]

Oh Boy. First go online and search for their "Obesity bulletin". Then follow it to the letter. in other words:

1. Make sure you have documentation - doctor notes, bills from Weight Watchers, whatever to demonstrate for at least 2 years you've tried to lose weight.

2.Get on any doctor supervised program for the next 3 months or more (I forget what it says for time). Make sure you have it all documented.

3. For surgery make sure you meet the BMI AND comorbidity criteria and this is big because I have high cholesterol, but not necessarily coronary heart disease...and my doctors assumed it did, but it did not.

4. AND even if you have the right BMI and comorbidity, they will only use lap band if you have a series of other condition they list which are not so common.

So yeah they cover the procedure, but but but but...

I am getting assistance right now with an appeal, but it is not looking likely. To counter point 4, I am arguing that I have issues that would have made the malabsorption under regular gastric bypass too much for me. Borderline anemia, wheat allergy, and B1 deficiency...

So it is a very difficult thing. I know Alex on these chat rooms had better luck.

[ppayne 0]

Has anyone used bandedlawyer.com or www.obesitylaw.com, did you have good results from them. I am trying to appeal my insurance company, and I am not sure who to use?

Thanks Trish P.

[ReneBean 3]

I'll let you know. I may end up using BandedLawyer.com (Steve Kalman). He has responded to my query. For $300 he will file my appeal with decent hope of success...

[ppayne 0]

I hope you have good luck, keep in touch with me how it goes. I will go thru this 6 week program 1st. then I will contact them

Trish

[ReneBean 3]

Well, because of the high BMI issue and the max 50 bmi allowed at blue cross, Steve has indicated that this is too complicated and given me another name: Gary Viscio gviscio@verizon.net

Steve was very nice, and honest enough to tell me that he was out of his depth - as well as being considerably less expensive than Obesity Law - so it is worth checking with him to see if he can help you.

At this point, I have also discovered that INAMED has a "Hotline" number for docs trying to get insurance approvals AND that they will assist the doc with appeals and actually write a letter to accompany your surgeon's letter.

**You must have been denied in writing to take advantage of this - AND the Hotline number is not available to the man on the street. They will only release it to your Doctor. I did manage to wring a copy of the required forms out of them, but aside from my release form, the doc has to complete all these.

Since there is a free option - and since I really don't have lots of money to fight for the cause, I am going to utilize this service.

It's a little complicated for me, because while I have had all of my pre-testing and submitted for pre-approval - I have never laid eyes on my surgeon. Surgery Center of Richardson works on an assembly line sort of basis. You don't do much with your doc except the initial informational seminar until AFTER you have insurance approval or financing in place. I went to a different doc's seminar - but was "assigned" to Dr. Fox because of my insurance company. Now, I am going to have to buck the system... Oh Well. SSDD.

I'll keep posting until we get it figured out...

[ppayne 0]

Thanks Rene,

I was turned down by ins, my BMI is 43, my Dr. can't believe they turned me down I have had all of my testing as well now ins wants me to go thru a 6 week diet thru my family Dr. He said he will play there little game and see me every 2 weeks for this then we will send it back in to them. If that does not work I will look into other options. Thanks

[ReneBean 3]

UPDATE:

I reviewed the Inamed bibliography - which was current thru 2004 - and have researched to find more current documented studies to combat the BMI issue and the Investigational issue. I am submitting my own appeal. If I have to go to the insurance board, I will get help for that.

I won't post the whole letter (4 pgs) but I will post the documentation that I am using:

From the FDA New Device Approval:

“When is it used? The system is used for weight loss in severely obese adults who have been obese for at least 5 years and for whom non-surgical weight-loss methods have not been successful. They must be willing to make major changes in their eating habits and lifestyle. Patients must have a Body Mass Index (BMI) of at least 40, a BMI of at least 35 with one or more severe morbid (unhealthy) conditions, or be at least 100 pounds over their estimated ideal weight.”

From the journal of Obesity Surgery, Volume 14, Number 8, Sept. 2004

“Laparoscopic Gastric Banding as Universal Method for the Treatment of Patients with Morbid Obesity” pp. 1123-1127 (5)

“Conclusions: LAGB should be recommended without limitation as the operation of choice for morbidly obese patients. Gastric bypass operations should be recommended only in cases of unsuccessful LAGB.”

From the journal Obesity Surgery, Volume 13, Number 3, June 2003 pp. 427-434 (8)

“Outcome after Laparoscopic Adjustable Gastric Banding – 8 Years Experience”

“Conclusions: LAGB is safe, with a lower complication rate than other bariatric operations. Reoperations can be performed laparoscopically with low morbidity and short hospitalizations. The LAGB seems to be the basic bariatric procedure, which can be switched laparoscopically to combined bariatric procedures if treatment fails. After the learning curve of the surgeon, results are markedly improved. On the basis of 8 years long-term follow-up, it is an effective procedure.”

From Surgical Endoscopy, Volume 17, August 2003 pp 1541-1545

“Laparoscopic adjustable gastric banding for massive super obesity (>60 body mass index kg/m2)”

“Weight loss with laparoscopic adjustable gastric banding in this group of massive super obese patients has been similar to all other surgical techniques with reduction of BMI from 69 to 33 kgs/m2 at 3 years. The relative safety of the Lapband avoids bowel surgery in these very big patients, suggesting that laparoscopic adjustable gastric banding is a valid surgical approach to these difficult patients.”

From the journal Obesity Surgery, Volume 15, Number 6, June/July 2005 pp.858-863 (6)

“Laparoscopic Bariatric Surgery in Super-obese Patients (BMI>50) is Safe and Effective: A Review of 332 Patients”

“Conclusion: Laparoscopic bariatric surgery is safe in super-obese patients. LAGB, the least invasive procedure, resulted in the lowest operative times, the lowest conversion rate, the shortest hospital stay and the lowest morbidity in this high-risk cohort of patients. Rates of all parameters studied increased with increasing procedural complexity. However, the difference in %EWL between RYGBP and LAGB at 2 and 3 years was not statistically significant.”

From Journal of the American College of Surgeons, Volume 201, Issue 4, October 2005

“Laparoscopic Adjustable Gastric Banding: 1014 Consecutive Cases” pp. 529-535

“Conclusions

LAGB can achieve effective and safe weight loss. Change from perigastric to pars flaccida technique reduced slippage rate. Preoperative body mass index alone was not found to be a predictor of effective weight loss in the long term.”

ADA Regulations for Title III

Sec..36.214 -- 36.299 [Reserved]

Subpart C -- Specific Requirements

Sec.36.301 Eligibility criteria.

(a) General. A public accommodation shall not impose or apply eligibility criteria that screen out or tend to screen out an individual with a disability or any class of individuals with disabilities from fully and equally enjoying any goods, services, facilities, privileges, advantages, or accommodations, unless such criteria can be shown to be necessary for the provision of the goods, services, facilities, privileges, advantages, or accommodations being offered.

[Guest miluckey]

Hello all,

I am also having trouble with "ins" my ins is UnitedHealth Care. And at this point I don't know what to do? But I am praying that everything works out for the both of us.

[Maggie63 0]

i have health american hmo through the federal government. they would have been happy to pay for the gastric surgery, but will not pay for the lapband (or so they say). my surgery is scheduled for 1 Dec 2005. my plan is to pay myself using a new credit card i got where there is no interest till 2007. i will give up whatever i have to to pay it off before i get hit with interest charges. i think i can do it.

i do plan on fighting the insurance company to pay. my primary care physician is supportive and i believe she will help me show i needed it.

has anyone been successful getting health america hmo to pay?

[ReneBean 3]

Inamed has a service that they offer to doctors to help fight insurance denials. Have your Doctor call Inamed and ask them about that.

[Guest md_new_band]

Hi,

This is my first post as well. I'm interested if anyone has dealt with Blue Shield of CA PPO insurance. I live in Maryland and and have Blue Shield of CA through my work. My personal physican is 200% in favor of banding. I have been told I might have an easier time getting approved if I have the proceedure done in CA. I am very willing to fly out. Can anyone recommend a good physican in CA who is willing to work with a refferal from MD?

I have requested a statement of coverage from Blue Shield of CA and am trying to get started with the approval process. Any helpful suggestions would be welcome.

Thank you.

Sue in MD ( but ready to head west)

[bandedredgirl 0]

I know steve. I used gviscio. he's at www.obesitylawyers.com I appealed, I hated having to pay but I got my band I think the insurance company should have to pay us back for our trouble when we have to appeal.

[BigBand 0]

Geezer Sue,

I like your style! I'm new to this board, and haven't really posted anything, but I've been reading voraciously. You are all so well informed - you're wonderful role models. I have Blue Cross in Minnesota. I'm 5'1, 211 pounds and miserable. I too have gone the route of every diet known to man, and joined Weight Watchers for quite a while. Although I would lose, I always gained the weight back and more. I want the quality of my life to be worthwhile. I want to run with my grandchildren at the park and maybe even find love again. My husband died 4 years ago, and although I would very much love to go out, this disgusting weight keeps all my dreams at bay. Any suggestions?

[kabasm 0]

Branso5111 -

The first thing I did was call my insurance company. They are the most knowledgeable about your policy besides yourself. Tell them specifically that you are considering gastric banding CPT CODE:43770. Ask them if 1)it is covered and 2) if it needs precertification/authorization and 3) if there is anything that needs to be done before authorization - that is - they may require a psych eval etc.. Make sure there has not been any break in coverage for at least the last 12+ months. If there is a break, they will make you wait until the anniversary of your policy because obesity then becomes a "pre-existing condition." I have an extremely restrictive policy and they "approved" me in 1 week with a lot of effort on my part and the fact that I had met all their conditions - psych eval, nutri eval etc..