Insurance Update...

kari_berry · September 27, 2004

OOOkkkay...here is the low down on my insurance.

I called my ins. co earlier, and spoke with someone to see if my insurance covers this type of surgery. I was told by the lady that she would have to find out, and call me back. Well - no one called me back, so when I was on lunch, I was talking to my Aunt about it.

Since she works in HR - she said that there is only one lady that she deals with at the insurance company. So she said she would call her for me and find out if they cover the Adjustable Gastric Banding procedure.

My aunt just called me back a few minutes ago, and informed me that they ONLY cover the procedure if it is Medically Necessary. The lady told her that normally they do not approve this procedure. She said that 99.9% of the people trying to get it, are denied. The lady who she spoke with said that I would have to go a PCP - and they would have to state whether they think I need the Adjustable Gastric Banding, or not.

So I guess from here - it's off to see my PCP. I'm definatly not getting discouraged about this, and this will not stop me from persuing the surgery. I'm sure it will take me a while - but I have nothing but time right now.

Thanks again for all of your support, and help answering my questions. You have all been wonderful to me!

~ Kari ~

New Hope · September 27, 2004

Kari, it's not over until it's over! Your insurance has definitely NOT ruled it out. That's wonderful! Now start writing down everything that you can think of to show why you need this. Don't forget your family health history, too. It will probably take time to jump through all their hoops. But getting healthier will definitely be worth it (for you AND the insurance co.) Best of luck to you!

kari_berry · September 27, 2004

Thanks so much

I will be making a doctors appointment sometime in the next two weeks for a physical. I may ask the doctor to try and put me on something to assist me in losing weight, and I can try that for about 6 months. (That's if my ins co. will pay for that.) Then if whatever the doctor prescribes doesn't work - it just gives me something else to use to my advantage I suppose.

I also want to go and get checked out for the chest pains that I have been having. I have no records of any of this, except for when I was in the 8th grade, I had bad chest pains, and had to get an EKG ect... (I don't remember the outcome of that test).

I figure, the more information that I can get in my medical record - the more it can help me. I don't want to try and appeal, with nothing to prove.

And later down the road, if they deny me, there is always the option to try and finance the procedure, or see if the insurance co. will pay half.

Thanks again for your help!

~ Kari ~

GeezerSue · September 27, 2004

If you're morbidly obese, the medical necessity part is a no brainer. I think I'd ask the PCP to NOT make reference to the TYPE of bariatric surgery, unless he can say that the LapBand is medically necessary. You don't want him to say that the RnY is what is medically necessary. It may be the "gold standard" in the US, but that surgery is a lot more deadly. (Have you had any previous abdominal surgeries? Sometimes those surgeries are a reason to not have RnY.)

Have you calculated your BMI? A big part of the medical necessity hinges on BMI.

Now, you have two weeks to get together info on the LapBand for your PCP. Doctors don't like anything WE say, because they are convinced that we don't know anything. You might want to call Inamed to find the most recent articles that have been published in "peer reviewed journals" that you could take with you OR you could have them mail to him right away.

Also, if you're good at wading through that kind of stuff, there are abstracts (the mini-book report version) of those articles available online.

Alexandra · September 28, 2004

Kari, with your BMI of 53 the medical necessity part is, as Sue said, a no-brainer. No insurance carrier or PCP would try to say that a BMI that high does not require treatment.

It's worth getting some info on banding for your PCP, but don't go in there all defensive. My PCP had never heard of it but was happy to read Inamed's patient booklet (which you can download from www.inamed.com). At this point you don't, I think, have to convince your PCP of the technical virtues of the surgery from A to Z or point his way to abstracts, etc. There will be time for that later if he's really balking.

Your PCP's role is to attest to your battle with obesity and bear witness that other methods of control have not worked. If this is your first physical with this doctor, that's the information you need to be armed with more than anything else.

LOVEMEACB4E · September 28, 2004

KEEP TRING EVEN IF THEY DENY YOU. THEY DENIED ME ONCE BECAUSE THEY THOUGHT THAT I WOULD GIVE UP. THEY WANT PEOPLE TO SHOW THAT THEY REALLY WANT TO HAVE THE PROCEDURE DONE. YOU MAY SPEND ALMOST A YEAR TRING BUT IT WORKS. I TRIED FROM OCTOBER 2003 UNTIL SEPTEMBER 19TH 2004.

kari_berry · September 28, 2004

Thanks for the replies I am going to print out some information on the band from the Inamed website to bring to my PCP.

I think first I am going to approach the subject of weight loss medication with my PCP. I've been reading that a lot of insurance companies want you to try other supervised means of weight loss for 6 months before they approve surgery.

So if the doctor can put me on something, and let me try it for 6 months or so, then atleast I could show the insurance company that I tried. Along with all my other attempts. Three of which were supervised, and documented.

I know that this surgery is not going to be an over night thing for me. I'm expecting 1 - 2 years of fighting. Heck, could be even longer, but I am going to keep fighting for it.

I just hope that one day - insurance companies will approve this procedure and save the lives of many people.

Thanks again so much for your helpful information! You are all awesome!

~ Kari ~

Alexandra · September 28, 2004

Hi Kari,

I went to my doc with the same request, and to my surprise she refused to prescribe something! My PCP is an osteopath and with her, drugs are the last resort. She just didn't think there was anything on the market that was safe and effective enough to prescribe.

Let us know what your doctor says.

GeezerSue · September 29, 2004

Not all insurances require medically supervised diets. Some require a five-year history of MO and evidence that you have tried other methods. (Your lifetime WW Membership Card or something.)

Again, I'm not an insurance expert, but I'll bet the farm on this advice: NEVER assume, and DO NOT EXPECT logic.

Alexandra · September 29, 2004

Originally posted by GeezerSue
Again, I'm not an insurance expert, but I'll bet the farm on this advice: NEVER assume, and DO NOT EXPECT logic.

LOL!! I'll take a little of that action, Sue!

kari_berry · September 29, 2004

Thanks for the replies once again.

I have yet to make a doctors appointment - but I have it written down at work so I cannot forget. I've been so busy at work (which is where I'm at now) that I don't have much time for anything else...lol.

I cannot wait to get the ball rolling on this. Atleast I'll have a start. I will definatly bring paperwork and brochures for the band, and I will also approach my Dr. about it. The worst they he/she can say is no...right? And then it's off to a new doctor.

I've decided first to go back to my old doctor's office (where my medical records are) instead of going to this guy that I've only seen once. Atleast at the other place, they will know my history, and I won't have to waste time trying to get medical records from them.

I was also thinking about getting my childhood medical records (from another doctor - if they have them). I don't know if that helps any - but it shows weight loss attempts when I was younger, and my weight, ect... I suppose anything that will help.

Anyways - I have to get going and finish up some work. Thanks for replying to all my questions / concerns. It really means a lot to me!

Thanks again!

~ Kari ~

hagerteresa · September 29, 2004

Best of luck Kari!!! Teresa

kari_berry · September 30, 2004

Thanks so much hagerteresa

Katie328 · September 30, 2004

Kari- I tried to be pre-approved by my insurance Humana and they told me the same thing..medically necessary. I was very worried because I only had a couple of co-morbidites besides just being fat...lol..I talked to all of the doctors I could think of, PCP, sleep apnea dr. and my OBGYN. MY OB wrote me a great support letter stating how it was medically necessary for me to have children to loose weight and how being overweight would affect all of my "female" stuff! I think all of my letters helped and I got approved on the first time! I made sure they all used the terminology MEDICALLY NECESSARY!!!!

Dont know if that helps but it's what happend to me

katie:Bunny :Bunny