New here - considering the Lap Band

[dishdiva 5]

Kari -- You are so awesome and courageous to be wanting this for yourself. If it works out, great. if it doesn't, you've learned that YOU think you are WORTHY of a better life for yourself....and you will find it!

Just glancing through your post, nothing stood out from your notes with your insurance company to suggest they wouldn't cover it. Mine (as of this year) very clearly stated in the "exclusions" that weight loss surgery of any type is not covered.

You've gotten tons of great advice from people here already. There are so many great web sites to answer your other questions. And, when in doubt, just ask!

I've had some complications, but would do it all over again if someone told me I'd be 50 pounds lighter. (Heck, I'd have done it for 40 or even 35!) It's certainly not my end goal (I'd like to lose another 40), but I'll take it!

And, as my nutritionist likes to remind me -- even when my food is looking crappy, if my exercise is there, I'm still doing good things for my body. So your efforts are not in vain!

Best of luck to you in your quest!

Elizabeth

8/28/04

[Alexandra 55]

I guess the thing that worries me is the "Not Medically Necessary" part. All the insurance co. has to say is - is that this is not medically necessary.

Kari, the good news is that just about every state in the Union understands that MEDICAL decisions shouldn't be made by your insurance carrier. It's your DOCTOR'S place to make the "medically necesary" call, not your insurer. Sure, they might say he hasn't made the case sufficiently to convince them to cover surgery, and that's their right, but then all the doc has to do is supply more information.

The American Medical Association has published guidelines on diagnosis and treatment of just about everything, and doctors and insurers rely on those guidelines. According to the AMA, Morbid Obesity is DEFINED as a set of conditions (BMI over 40, or BMI over 35 accompanied by two co-morbidities) that if present, require treatment. That's why you often see exclusions worded as I described earlier. So, if you have the condition--and that diagnosis code of 278.01 is present in your record--you really can't be told treatment is not medically necessary.

I think you're in very good shape, insurance-wise. Get thee to your primary care doctor for a physical as soon as you can and open the conversation about bariatric surgery. Your carrier might very well require evidence of prior dieting experiences, or at least one more attempt at a doctor-supervised diet of six months or so, but nothing will ever get off the ground unless you get that physical.

Keep us posted!!

[kari_berry 0]

Wow - thanks again for the replies. You are ALL wonderful, and supportive!

I think monday will be the day that I call my insurance co. and see if they cover this surgery.

I will definatly get in with my doctor, and see about getting a physical. I haven't had one of those in a loooong time...lol.

Oh - I also wanted to know.... how do you know if the doctor will put the 278.01 code on the paperwork? Do you have to ask him to do that?

Luckily - if my insurance co. needs some type of proof that I have been on "diets" ect... I can give it to them. I *should* be able to get the records from the Medical Weight Loss clinic from back in the mid 1990's. And I should also be able to get the paperwork from a year ago when I was attending their program. Also - this past summer I signed up for the L.A. Weight Loss center, but quit two weeks later, because I was so discouraged about my weight. I should be able to provide them with that paperwork too.

I used a BMI calculator today, and found out that my BMI is 53!!! Sheesh. I feel so yucky about that. How I let myself get this far out of control - is beyond me! Now it's time to try and take control of my body!

Thanks again for the replies. I will call the insurance co on Monday - and let you all know the outcome of everything!

~ Kari ~

[rharriet62 0]

Kari,

My insurance changed with my job in July of this year. I had been on Blue Cross of WY and when I called to ask them if they covered it, they said they did cover the bypass, but to submit reasons why I wanted a lapband thru my doc. That claim was denied, but by then, I had new insurance with Beech Street. I called Beech Street several months before I was even a member and asked if they covered weight loss and they said YES. I asked if they had ever covered any lapbands, and they said they had covered several in the last few years. I got approved with MINIMAL hassle! They were awesome. Then, my employer sent out our coverage booklets, and weight loss was listed as "excluded" except with medical necessity to be proven. I had to show a medical history, a medical supervised diet (I had done phenphen about 10 years ago), and had to get a psych eval. That was it. Honestly, that exclusion paragraph would have discouraged me had I not been approved! SO, all this means, YOU JUST NEVER KNOW!!! Go for it. I even had a friend who paid big bucks to BC/BS for 6 months on high risk insurance so she could get a bypass...and they paid if for her after 6 months! SO, there are ways around it, too, without being stuck with the whole cost.

I would just call and ask about a coverage claim and see what happens. All information is good information!!!

As for your other questions, I had surgery on Tues in CO and I am tired today, but no pain meds needed...just sleeping and taking it easy! It was honestly much easier than I had prepared for.

Good luck!

Rose

[kari_berry 0]

Hi Rose - congrats on getting banded! Glad to hear that everything is going well for you so far!

I am feeling more and more positive about this. I get a little nervous about the whole insurance thing, but I know I can fight it. I'm strong lol.

Please keep me updated on your progress Rose! You'll be feeling great in no time at all!!!

Thanks again!

~ Kari ~

[Alexandra 55]

Kari, when you're at your doctor's for the physical just tell him or her what you're hoping to accomplish. With a BMI of 53 you really won't have any problem meeting that medical-necessity yardstick, and if you tell your doc to give you the diagnosis I promise you he or she will.

The code may not actually appear on anything YOU read, but if your doctor is an in-network provider his office will have to code everything in order to get paid. Just mention that you definitely want that code and/or that diagnosis in the insurance record.

[kari_berry 0]

Thanks Alexandra

I will be sure to do that. Could it also help if I give my doctor a copy of my medical records?

I just got my health insurance back on the 1st of July - and have only seen the doctor once. (And this is a new doctor - no one I've seen previously).

The last time I actually went to my family physician - I was 18 or 19 years old. Now my physician no longer there due to his own health reasons.

Can my new doctor even keep my old medical records? Just curious if this would help me out too - seeing as my weight has always been an issue since I was little.

Thanks again!

~ Kari ~