Getting ready to visit the PCP to get a referral for the band. Advice?

[kimster 0]

Hi Everyone:

I have an appointment with my PCP on 8/6, and I'm getting a little nervous (OK, and excited too!). I want to make sure that I get a referral for the Lap Band, and NOT for RNY. The insurance company says, "According to your contract with Kaiser Permanente, you do have benefits for Gastric Bypass surgery but will have to meet certain guidelines and an approved authorization for this procedure." When I asked Kaiser if they covered Lap Band, that was the response I received. So, I don't want them to say, "yes, we'll cover RNY, but no, we won't cover the Lap Band."

Here's my situation. I'm 38, 5'3" and about 295 pounds. My BMI is over 40, so according to state law, they have to cover me for gastric bypass surgery. I guess my question is, what can I tell my PCP to get him to back me when I say that the Band is the right kind of weight loss surgery for my situation?

Just want to be prepared to fight the fight!

Thanks!

[hagerteresa 3]

Hi Kim,

Alex has a fabulous sample letter she used to fight her insurance company over the same arguement and she won. The letter is in the thread: Insurance. It is very professional but she said it needs a little updating if people want to use it now. Best of luck, Teresa

[sassaay 1]

Hi Kim,

I will be curious to see how your Quest for LabBand via Kaiser goes. I am not trying to rain on your parade, but my Mom works for Kaiser here in Northern CA and has spoken with many Kaiser employees who wanted LapBand, but Kaiser said 'no', but 'yes' to RNY.

I will keep my fingers crossed for you. It would be great if more HMO's and insurance companies would realize the benefits of LapBand.

Good Luck!

[kimster 0]

Thanks for the help Teresa. I can't seem to find that post. I tried searching, but it pulls up about a cajillion responses. Can you help???

Thanks,

Kim

[Alexandra 55]

Hi Kim,

Here's the link to the thread that has a couple of appeal letters in it:

http://lapbandtalk.com/forum/showthread.php?s=&threadid=2527&perpage=15&pagenumber=2

At this point all you're doing is getting a referral from your PCP to explore weight-loss surgery. Don't worry about what TYPE of surgery yet; that's not a call for your PCP to make. Once you get the referral to a surgeon, start going for all the diagnostic tests and whatnot that the surgeon requires. The first step is to get the doctors and Kaiser to agree that you are a good candidate for surgery at all.

Then it's your surgeon who will be putting in the request for pre-cert for the surgery itself, and at that point you need to be all over the lap-band vs RNY thing. Make sure the surgeon's office requests the correct surgery, and if you are denied make sure you know exactly why. Then take it from there. Good luck!!

[kimster 0]

Thanks for the link and all of the information!!! I really appreciate it. Tomorrow, I visit my PCP!!!

Thanks!

[DaisyGirl 0]

Hi Kim,

I am at about the same point you are. I did already get the go ahead from my PCP and met with the surgeon But I just wanted to let you know I know how you feel I wa so affraid that my PCP would not be on the same page as me I went armed with tons of info and let me tell you If I was this prepared while in school I would have made straight A's all along..lol

But to my surprise My PCP was totally on my side and I never needed all the info I had with me. She gave me my referal and now I am off and running. I Have an appt. with the cardiologist and pulminologist this coming week.

I have Aetna insurance and they wont cover the surgery either.

So I wish you oodles of luck. and who knows maybe we will be having our suregery dates close together...lol

Amy

[Alexandra 55]

Amy, don't be so quick to discount Aetna. They've rewritten their coverage determination with regard to the band and I think as long as you can get your doctors to make a strong case for band over bypass you have a good chance.

You might want to spend some time working on a list of reasons you don't want bypass. If you have any medical issues that make the bypass even marginally a bad choice, write them down. If your first request is denied that will probably be the course you have to take in convincing them.

Good luck, and I'll be very interested to hear how things go!

[kimster 0]

Here's how it went:

First off, I picked a really bad day to go see my PCP. Of course, I didn't realize it ahead of time, when I scheduled the appointment. I started my period a couple of hours after the office visit. Plus, the day before, I spent most of the day in bed with a Migraine from hell. So, I felt very emotional and fragile -- definitely ***not*** me. While I was at the appointment, talking about my reasons for wanting to have the surgery, I completely fell apart and started crying. Fortunately, I've known my PCP for over 3 years, so he knows that I am not normally so emotional. Otherwise, I'm sure he would have figured I was a complete nut case!

Kaiser doesn't currently cover the Lap Band. I pretty much figured that to be true when I walked in the door. They'll cover other weight loss surgeries, just not the Lap Band. My PCP asked me what I would do if Kaiser still didn't cover it at the time of surgery. I said I'd probably end up going to Mexico and self-paying, because I didn't want to have my intestines butchered with the RNY, and I couldn't afford to pay at least double what it would cost in Mexico.

Kaiser has an interesting "process" for everyone considering wls. Before my PCP can give me a referral, I have to have a psychiatric evaluation, attend one of Kaiser's weight loss classes, meet with the nutritionist at least 6 times in 6 months, and lose at least 5% of my weight. OK, personally, I think the 5% weight loss is total BS, and I told him so. After all, I've lost weight many times in my lifetime. I lost 70 pounds on NutriSystem once, 30 pounds on Jenny Craig 3 times, and have been on diet after diet since age 8. I probably know as much, or more, about nutrition as the nutritionist. So, IMHO, I think this is bogus.

So, what do I do? I'm going to comply with whatever it takes to get Kaiser to cover ANY wls. So, that means I will do the classes, lose my 15 pounds, meet with the shrink, etc. I will prepare to fight a denial when I ask for the Lap Band. And, I will prepare to do my surgery in Mexico if it doesn't work out.

Anyway, I thought you'd all like to see an update, so I thought I'd share how it went yesterday. I've got a bunch of work to do today, so I need to go. More soon.

I'm off to make Mint chocolate Truffle Organic Sugar Body Scrub now...

[Alexandra 55]

Kim, though it all must have been and continue to be frustrating, I applaud your determination and serious sense of purpose! It's more than possible that by the time your six months is up, Kaiser will have re-examined their stance on the band. And if not, well, there will be six months more time for a body of evidence to build about its effectiveness.

I'm sure you will prevail with that level head of yours. You remind me of me, exactly two years ago. :eek: :eek:

[kimster 0]

Thank you Alex! Your support means a lot!

[New Hope 37]

Kim, hang in there! You're doing the right thing. As far as getting upset at the drs. office, don't worry about it. We've all "been there and done that". My insurance first denied, then after my appeal, finally allowed it 8 months later. Just jump through all their hoops and get all those referrals! I'm betting on you!

[DaisyGirl 0]

Alex,

Thanks for the heads up on Aetna. I am going to get busy and write down everything so I can get them to cover me. At least I know there is some hope..lol

Amy