Please help, where to start?

[somethingelse 0]

I've posted a few times now but I'm confused as to exactly where is the best place to start on my journey towards the band? I have an appointment coming up with my family doctor that I already had for a med check and I plan on bringing up the idea with her.

But I'm wondering do I contact my insurance company first? I looked up on their website and from what I can see they do cover the band if you have a BMI of under 50 (mine is 50 but I'd only need to lose 5 pounds to lower it).

I've found a doctor about 2 or 3 hours away that has done a ton of bands and I'd like to possibly check out one of his seminars. But someone mentioned on another of my posts to see which docs my insurance will cover first.

So how do I go about doing that? Do I just call up my insurance company? I just get nervous dealing with them because I'm so afraid of being denied.

I'd love to hear from you all as to which steps I should take first. I feel like my wheels are spinning but I don't know where to go. It's gotten to where I can't sleep at night with thoughts of this all. Right now it seems just out of reach if you know what I mean. I feel overwhelmed. Thanks for all your help so far, you guys are great!!

[momlambert 77]

I don't think it really matters what order you do things in, but I didn't have insurance to cover mine so someone else will have to speak to that. I did call our insurance company and just asked them what I would need to do to be covered but, since they don't cover any WLS, that was a dead end. Starting with your primary care dr. is a good choice. I did that and then I went to a seminar where they told me that my insurance wouldn't cover it (by then I knew that). So you will probably feel like you are going in circles for awhile, but each time you circle about you get new information so it's not wasted! It's just a process that you need to start somewhere. And if you attend the seminar of that dr. and he isn't covered by your insurance, you've gained valuable information and direction toward another path. It's all a learning process. Good luck!

[musicalmomma 1]

I've posted a few times now but I'm confused as to exactly where is the best place to start on my journey towards the band? I have an appointment coming up with my family doctor that I already had for a med check and I plan on bringing up the idea with her.

But I'm wondering do I contact my insurance company first? I looked up on their website and from what I can see they do cover the band if you have a BMI of under 50 (mine is 50 but I'd only need to lose 5 pounds to lower it).

I've found a doctor about 2 or 3 hours away that has done a ton of bands and I'd like to possibly check out one of his seminars. But someone mentioned on another of my posts to see which docs my insurance will cover first.

So how do I go about doing that? Do I just call up my insurance company? I just get nervous dealing with them because I'm so afraid of being denied.

I'd love to hear from you all as to which steps I should take first. I feel like my wheels are spinning but I don't know where to go. It's gotten to where I can't sleep at night with thoughts of this all. Right now it seems just out of reach if you know what I mean. I feel overwhelmed. Thanks for all your help so far, you guys are great!!

Hi somethingelse :wave: Our insurance is through my husband's employer. I emailed their benefit's specialist first and asked it WLS was an inclusion on the policy. It was...THEN I contacted the surgeon, made an appointment for a consultation. Went to the consultation. THEN, called the insurance company and asked them to send the specific requirements for Bariatric Surgery. From there...the surgeon's office took over and did the rest of the insurance leg work for me.

I think you just may have misread the requirements regarding BMI. Our insurance (and most I've heard of) won't cover the band if your BMI is OVER 50. They cover a bmi of 40-50 (35-40 if there are comorbidities).

So, if you're comfortable talking to your benefits rep in HR, I'd start there. Otherwise, call your carrier and do NOT let them just brush you off with a "it's not covered"...make them send you that portion of your policy. They tried to tell me we weren't covered for WLS, I told them, "look again, because I KNOW we are". Sure enough, after being placed on hold for a few minutes, she came back and apologized for the misinformation.

Good luck!

[somethingelse 0]

Great information guys. Actually my insurance says something like the band is investigational or something like that for anyone with a bmi of either 50 and up or over 50. I can't remember 100% what it said but I am almost positive it was for 50 and up and then for that they won't cover it.

I guess I need to just suck it up and give them a call. Will they actually give you a list of doctors too?

[tanderson 3]

I guess I need to just suck it up and give them a call. Will they actually give you a list of doctors too?

They should be able to tell you your participating providers, or you can ask if the surgeon whose seminar you are interested in attending is covered by your policy. If he/she is a participating provider, go to the seminar first and they should be able to direct you as to your next step(s). My surgeon provided an entire portfolio with a plethora of information that was extremely beneficial for the pre-op process. By the way, what insurance do you have?

Peace Out!

T~:hippie:

[somethingelse 0]

Okay bear with me here everyone but here is word for word what they have written on BCBS website:

The first treatment of morbid obesity is dietary and lifestyle changes. When conservative treatment fails, a few patients may require a surgical approach. A 1991 National Institutes of Health (NIH) Consensus Conference defined surgical candidates as those who meet the following criteria:

• Patient has a BMI of 40 kg/m² or greater than 35kg/m² in conjunction with severe comorbidity such as cardiopulmonary complications or severe diabetes
  
• Super obesity described as BMI >50kg/m²
  
• Failure of sustained weight loss with supervised dietary and conservative treatment over the years
  
• Motivated individual with acceptable operative risk

Surgery for morbid obesity, also known as bariatric surgery is based on intestinal malabsorption and gastric reduction. Surgery is considered successful if weight loss is maintained at greater than or equal to 50% of excess body weight for more than 10 years.

Prior Approval is recommended for this service. Submit a prior approval now.

The following surgical procedures for the treatment of morbid obesity may be considered medically necessary when the criteria for coverage listed below are met:

• Vertical-banded gastroplasty
  
• Gastric bypass (Roux-en-Y gastroenterostomy); this can be done by both open or laparoscopic approach
  
• Adjustable gastric banding (Lap-Band® procedure) for patients with a BMI less than 50kg/m²

Criteria for Coverage:

• Patient is at least 18 years old

And

• The patient must have a documented medical history of failure to sustain weight loss with medically supervised dietary and conservative treatment for at least three years including within two years preceding surgery. Medically supervised treatment consists of physician documentation of the assessment of the patient, what health interventions are prescribed and their on-going assessment of patient's progress toward a goal of weight loss or control of an obesity-related comorbidity.

And

• The patient must be a motivated individual with acceptable operative risk and must be evaluated by a licensed mental health provider to determine the patient's willingness to comply with pre and postoperative treatment plans, and a strategy to ensure cooperation with follow-up must be documented.

And, in addition to the general requirements above, the patient must also meet one of the following weight criteria:

• BMI of 40kg/m² for at least 3 years

Or

• BMI of greater than 35kg/m² in conjunction with at least one of the following:
  • Hypertension requiring medication for at least one year
    
  • Diabetes Mellitus type 2 requiring medication for at least one year
    
  • Obstructive sleep apnea, confirmed by sleep study, which does not respond to conservative treatment
    
  • Documented cardiovascular disease
    
  • Pulmonary hypertension of obesity

Or

Super obesity described as BMI greater than 50kg/m² for vertical-banded gastroplasty and open or laparoscopic gastric bypass (Roux-en-Y gastroenterostomy).

The following surgical procedures for the treatment of morbid obesity are considered investigational:

• Adjustable gastric banding (Lap-Band® procedure) for patients with a BMI equal to or greater than 50kg/m²
  
• Mini-gastric bypass (laparoscopic)
  
• Biliopancreatic bypass with duodenal switch
  
• Laparoscopic silicone gastric banding
  
• Biliopancreatic bypass (Scopinaro Procedure)

Subsequent bariatric procedures, including revisions, in patients who regain weight due to failure to comply with lifestyle or dietary modifications are considered not medically necessary.

Okay so if I'm reading this right to be covered for the lap band I have to have a BMI just under 50. Also the part where they talk about needing to have tried and failed doctor supervised weight loss efforts for THREE years!!! I haven't really had any doctor supervised stuff, at least not for a really long time. Other than with both of my pregnancies I had gestational diabetes and obviously had to follow the diabetic diet for both my health and that of my babies. I did lose forty pounds or more during each of my pregnancies and then within a matter of about two or three months I gained that amount back and more both times. I don't know if that would count but I'm guessing not.

I do know that our hospital is now offering this six month weight loss clinic thing where you work with the dietician,doctor,and trainer. In the literature I read for it it says that it usually satifies most insurance companies rule for having doctor supervised weight loss efforts.

Do the insurance companies really stay strict about the having shown you've tried losing weight with the help of a doctor? If so that sucks because if that was the case I would've been doing something about it with my doctor and not just on my own. The thing is a person can only see the dietician so many times KWIM? I know what I should eat, I just can't stick to it or I wouldn't be in the shape I'm in.

UGH, I am soooooo upset. If I have to wait another three years I'll be devastated. Has anyone gotten around that? I just wish I had realized this.

[LovelyLaFleur 0]

Yes, they are strict. But, I would go to your primary Dr. Who can refer you to a Surgen. I would also submit for Prior approval. WhenI did they wrote me a letter and told me step by step what was needed to qualify. Your on the right track. I know that my Dr. doesn't really like to do the banding if you over 50. GOD LUCK

[LovelyLaFleur 0]

Sorry about my spelling my keys are sticking and didn't realize it

[musicalmomma 1]

Adjustable gastric banding (Lap-Band® procedure) for patients with a BMI less than 50kg/m² (had to say "told you so" hehehe...totally kidding here)

I would strongly suggest just diving in and going for it. Print out what you just posted and take it with you to your consultation. A GOOD surgeon's staff will have a MUCH better idea of what is writting in stone and what can be manipulated or worked around. You may even need to appeal. My husband is appealing right now. The Obesity Law & Advocacy Center has taken his case and is fighting for him as I'm typing.

I know you're full of questions and you're wanting to know up front if you'll be approved. After all, who wants to do all this work and be denied? But there is just no way to know what the insurance company will do for 100% certain. Yes, it would be terribly disappointing if you began the process, even got a few months in, and got a denial, and had to appeal and perhaps be denied again or told you have to stay on the supervised weight loss longer. But look at it this way...you'll still take of weight, you'll feel better and you'll be healthier. I had to give up on the idea of "either/or". Meaning, "either I get approved or I get fatter". I had to decide that I'm going to lose weight no matter what the outcome. I know that I'm looking at heart disease and type II diabetes and a variety of other co-morbidities if I didn't take control somehow. I am pleased as punch that it will be easier because of the band, but I just had to set in my mind that either way, I was going to get healthy.

I hope this helps a little. I know it's frustrating, not knowing it all up front, but it's worth it, no matter what the outcome.

Best wishes

[Carrie E 0]

I call my insurance to find out what doctors and what hospitals do what I need or would like to have done (the band) and they help me figure out how to use their web sight or just give me the info over the phone. I went to a seminar first and then saw my family doctor and asked her to write me a letter of necessity and send it to my insurance (my insurance wouldn't pay for that visit but it was minimal cost) My doctor was perfectly happy to. Then the Surgical Weight Loss Center filed with my insurance and called me back to let me know which Doctor, in their practice, was in my network and that I couldn't use their new facility BUT the doctor that I had to use also did the surgery at KU Med in Kansis City (in my network) and I was in surgery 2wks later! I did it backwards but it happened to work out for me! Call your insurance and DON'T BE AFRAID OF THEM or being turned down!!! The lady I talked to at my insurance company, was asking me all kinds of questions about the lapband because she was interested in getting it done, too! Best of luck!! Get busy doing it, you'll kick yourself later for letting so much weight losing time go by.........I'm still kicking myself

[michellyoh 0]

I first talked to my primary care physician (PCP). He was very supportive, and even referred me to a surgeon (that he knew took my insurance). One of the requirements my insurance company had was a documented weight loss plan for the past 6 months. I told my PCP about this, and he wrote a letter to the surgeon, and included all of the dates I had been in to see him in the past 2 years. Because no matter what my reason for going to see him was, he always asked me how I was doing with my weight. My insurance company accepted this and I was approved! I know that BC/BS is a little more strict than others, but you can always appeal their decision. Whatever surgeon you choose should have a patient advocate that can help with all of the insurance mess.

I would move forward with your plans. Good luck! And we're always here if you need us!!

[Big As Life 0]

I started out going to the seminar first....then once I had the info I needed, I made appointment with the docotor that had the seminar...then I had them check with my insurance co., to see if they would pay for the surgery..I was denied...for two years I went back and forth on trying to make my decision...finally, I decided I would do the self-pay...made another appt and went in to see the doctor and was told to start two week liquid diet on the upcoming Friday(this was on Monday) and then two weeks later I would have the surgery...Boom...it was all set up and I was ready to go...best decision I have ever made...

Good luck to you...I hope that all goes well....

[goodtimes 0]

hi somethingelse; you can start going to the seminar and preparing for an appointment with the dietian and surgeon. you also can call the insurance company as well. but with me i have blue cross, blue shields i had to go through sleep apnea, dietian a few times. they actually had to have documented records to send to the insurance company. it took 5 months but the surgeon was really indepth with me and how they set high standards.

[goodtimes 0]

yes, in the documentation, there must be some info. documented that you have lost weight. did you say you had blue cross blue shields

[cin 0]

Fist of all take a deep breathe, this won't happen over night i've been in the process for well over a yr and in March got my denial now i'm appealing it and my case is pending.

The first thing i did to get started was attend a lapband semiar with the surgeon and from there his nurse was handing out phamplets, once those were filled out then they called me within a week to schedule an apt with the docotor and here i am over a yr later dealing with my insurance company. I have Cigna Health care they require that we see a Dietitician for 6 months along with all the other requirements so my 6 months is up this month now i'm back to the waiting game once again will i be approved or not.

Please don't get frustrated or lose sleep over this if you want to lose the weight bad enough then it takes time depending on your insurance company.

Good luck,

cin