Waiting for Insurance Approval

[DaisyBell 28]

Hello everyone!

I just wanted to stop by and introduce myself. My husband and I are close to retirement and hope to hit the road in our RV to see the country. And, I am looking forward to retirement as a healthy “normal weight” person instead of an overweight, out of breath, huffing and puffing old woman trying to get around seeing new sights and places. So, I have decided to have lap band surgery and have already had a wonderful visit with my surgeon. He has agreed to do the surgery and has submitted the request for approval to my insurance company (August 13^th). So now the waiting begins.

I am very excited about the procedure as I have a sister and a nephew that have done awesome with the lap band. I also have a sister that had the RNY surgery and is doing great. As you can tell the heavy gene runs in my family.

My daughter is an RN and she supports my decision wholeheartedly and my husband is okay with it but I think is a little confused as why I can’t take the weight off by myself. But, he has watched me struggle over and over to lose weight only to fail or gain it back as soon as I went off the diet.

I need something that will provide the “hard stop” and tell me I can’t eat anymore. I know the band is a tool that does that and that I have to work with the band to lose the weight.

So happy to have found this site and look forward to the support and information that is here.

[labwalker 1,177]

Congratulations on the retirements and for your decision to take charge of a healthy future!

I was in the same situation! Shortly after retirement I seriously started looking at WLS options. I wanted to travel, and to enjoy my remaining time doing things, and being active. Dealing with tight plane seats and no leg room, and not being able to fit into booths at restaurants was depressing. I dreaded the thought of flying! I even had to ask the room attendant on a few cruises to find a larger sized chair for my balcony.

You are spot on about being able to lose the weight, only to eventually see it all return, and maybe a bit more to add some insult!!! I've tracked my weight for over ten years and I've been able to lose, but I was never able to keep it off. The band has helped when I've been lax--I hold my weight instead of putting the pounds back on. I within several pounds of the lowest weight I've been able to achieve in the past 20 years, thanks to the band.

Give your band time to work... there is some time needed for healing, before the fills can start... it may take a few months before you see any results after the surgery. Unlike other procedures, success with the band requires frequent follow visits and a bit of effort to track your food and Fluid intake.

Keep up the positive attitude, you will succeed! Congratulations on making a positive life changing decision. And most of all, lose the weight, travel in comfort, and enjoy your retirement!!!!

[DaisyBell 28]

Thanks so much for your words of encouragement. The waiting to hear from the insurance is going to seem like an eternity. But in due time it will all workout.

[doingitforme29 8]

Well today I had a consult with a surgeon who specializes in bariatrics. I was weighed in at 229 lbs and a height of 5'4, which makes my BMI 39.3. Firstly, I've always been measured at 5'3. The surgeon stated I was a great candidate for the lapband procedure but stated my insurance would not pay because my bmi isn't 40. He stated my insurance requires my BMI to be 40 or 35 (with a co-morbidity) for the past three years. He did not see what could be done to help me qualify nor did he request to retrieve my medical records from my pcp or other physicians. I immediately contacted my insurance company and they stated they do not have to have pre authorization, but there's a possibility they may request info in the future and if they find it was not medically necessary, they would withdraw the benefit. My insurance company gave me the info for a doctor who has a 98% approval rate. I do not have any comorbidites other than asthma, very infrequent menstrual cycles, and infrequent high blood pressure. I spoke with the staff at the doctor's office my insurance company referred me to and she was very optimistic about being able to help get me approved. I prayed before I went in the doctor's office asking God to reveal the best option to me, I can't help but wonder if I'm going against God's answer to my prayer by seeking approval through another physician. Having this surgery is very important to me. It's something I have desired to do for the past three years. I really want this. I know of a lady who has the sleeve and was denied twice before she received approval. How often do people get approved after being denied. I wasn't denied by my insurance company. The doctor simply didn't try seek approval from my insurance. The moment the calculated my BMI and saw that it was 40, they were pushing me to finance the procedure. Advice anyone. What should I do? How do I get my insurance to pay?

[DaisyBell 28]

Sounds like that surgeon is in it for the dollars and not your health. The insurance must trust the one they recommended or he wouldn't have such a high approval rate. I would check with the recommended surgeons office and see what they way. Ask for some names of people that have had the surgery that you could talk to about their thoughts and experience with him.

My surgeon holds information sessions once a month and that was my first step to see what he said regarding the different types of surgery. He is also the surgeon that did my sisters and nephews surgeries so I know some history on his work. Also, he is the one my daughter recommends and she is an OR nurse in the same hospital and does many surgeries with him. I am sure you can find information about the other surgeon.

Also, maybe this is God's way of keeping you from going to the wrong surgeon. You may have had problems if you had went to someone who was in it for the money and not your health.

[doingitforme29 8]

Thank you so much got your feedback. I didn't think of it as gods way of preventing me from going to the wrong surgeon. I can't help but think that the dr didn't bother requesting my medical history from my previous physician or anything. He didn't even emphasize what I needed to do to get insurance to pay neither did his staff. They were adamantly telling me to finance it through care credit. Immediately after speaking with the nurse at the dr my insurance company referred me to, they were very optimistic, asked me to get my medical records, informed me of the option to use photos, etc!! I received my medical records from my previous physician and every document has my height listed as 5'3 contrary to what the dr claims I was yesterday. I have been 5'3 since high school. That alone made me feel as if that dr didn't have my best interest in mind. I'm scheduled to attend the preferred dr's seminar or September 2nd and hope things improve from there.

[DaisyBell 28]

Sounds like you are on the right path with a good doctor. Hope it all works out okay.

[doingitforme29 8]

My only concern is that my records have me being 5'3 and my BMI increased to 39 and has recently become 40.3. My comorbidities include hypertension, fatigue, and constant weight gain. My menstrual cycle has been irregular for the last three years, which I think is because of the weight gain. Is that enough to get me approved? I've been really stressing about it since my appointment with the money hungry surgeon from hell. My husband thinks it was gods way if preventing me from going to a surgeon who didn't have my best interest in mind. I'm hoping this new surgeon helps get me approved. Hopefully he'll include pictures as well. I'm stressed but excited to be going to a new surgeon.

[DaisyBell 28]

I sure hope it all works out well for you. Keep us posted on your visit to the surgeon.

[DaisyBell 28]

So, I called my insurance Tuesday to see if they had received the request to approve the surgery and they did not have a record of it. Ok, so I called the Bariatric Coordinator and she resent it with a note "2nd Request" and the next day she received a voicemail from the insurance that I met all criteria but I had to go through nutritional counseling. I was so frustrated! Both she and I had called and there were no pre-requsites only medical necessity. So, she called the insurance company back and they have not returned her call as of this afternoon.

I have also reached out to our HR Benefits Director to check on this as both myself and the Bariatric Coordinator were told that there were no pre-requisites. I specifically asked was there anything else needed such as psych eval, nutritional counseling, etc. and they say no...just medical necessity.

So, still waiting for an answer. Please keep me in your prayers that this will get cleared up quickly.

[OhSoNique 84]

So, I called my insurance Tuesday to see if they had received the request to approve the surgery and they did not have a record of it. Ok, so I called the Bariatric Coordinator and she resent it with a note "2nd Request" and the next day she received a voicemail from the insurance that I met all criteria but I had to go through nutritional counseling. I was so frustrated! Both she and I had called and there were no pre-requsites only medical necessity. So, she called the insurance company back and they have not returned her call as of this afternoon. I have also reached out to our HR Benefits Director to check on this as both myself and the Bariatric Coordinator were told that there were no pre-requisites. I specifically asked was there anything else needed such as psych eval, nutritional counseling, etc. and they say no...just medical necessity. So, still waiting for an answer. Please keep me in your prayers that this will get cleared up quickly.

Awwww that sucks. Hopefully u get that all cleared up. When you first started the process they didn't give u a written list of requirements? If so and that's not on there than they can't just spring it on you. I submitted my papers to both my insurance n the hospital August 15 n good thing I did bc I called my insurance company on Monday n they said they r waiting on the clinic and so after I called the clinic n they said the nurse is reviewing the psy eval n then they can submit to my insurance I was like ummm I'm one step ahead I already did they just waiting on you lol. So I wish u good luck!!!

[DaisyBell 28]

OhSoNique,

I had called the insurance to see what the requirements were and was told only "medical necessity." I specifically asked during the phone call were there any requirements such as psych eval, weight counseling, nutritional counseling and was told that medical necessity was the only requirement.

The Bariatric Coordinator for my surgeon had also verified (by phone) what were the requirements and she was told "medical necessity" was the only requirement. So, that was the information we started with and then they came up with the nutritionist thing.

Another girl at my work who had the band had to have emergency gallbladder surgery and the surgeon unfastened her band because it had slipped. Evidently, once they slip the likelihood of the band slipping again is much greater. She is looking to do a sleeve. When she had the band surgery she only had to have a sleep study. Same insurance now wants her to go to nutritionist before they will approve the surgery.

It appears the rules change at their discretion.

[OhSoNique 84]

DaisyBell I'm sorry u have to go thru that, that's not fair at all. You know how you call somewhere n one person tells u one thing n u call back back and the next person something else. I would ask for a supervisor, and ask for written document that says that when did it go into effect. Make sure u remember the dates you called or started the whole process. Also that's sucks about your friend, she already had wls just now a revision is needed. What insurance is that? Smh