IF you have had dealings with INSURANCE please help!!

[KayKay 0]

Ok here goes. I have BCBS of Tennessee, I know that insurances and policies are different, I meet all the requirments for the Lap Band Surgery with the exception of losing 10% of body weight (if I could lose the 10% of body weight what's the point of having the surgery) anyways, the following is in the insurance in order for them to pay:

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<LI class=kadov-P>The attending physician must submit evidence that the attempt at conservative management was within two (2) years prior to the planned surgery; and

<LI class=kadov-P>The attending physician must submit records that the individual has successfully lost 10% of initial body weight prior to the date that the authorization is requested;

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Can someone help me make heads or tails of this? Maybe I am just worried since I am scheduled to have lap band suregery in two weeks, Like the rest of you, if I could lose weight then why have the surgery.

Any advise is greatly apperciated!!

Best regards,

KayKay :help:

[Wheetsin 714]

Like the rest of you, if I could lose weight then why have the surgery.

Oh, I had no problem losing the weight. I lost the weight probably 5 times. Many companies want to see the 10% loss to prove that you have the ability to lose weight. Losing 10% excess weight, and getting banded, aren't the same thing. Many of us could lose 10% without thinking twice (that's 10 lbs? 20?) but could never maintain. That's where the lapband comes in. Providers feel that proving the intiative and ability to lose weight is indicative of a higher success rate with the band. And they're probably spot on.

So, going on what's written there, I would think they're looking for medically documented weightloss. Usually going to the office for other things, and getting weighed while you're there, won't work. Same as with medically supervised diet. You have to go and have the visit coded for the specific purpose of weightloss (treatment for MO, or whatever the term is).

So basically, did you lose 10% of your weight within the last 2 years, AND did your doctor submit proof before you submitted a request for coverage. If either of those were not done, they can deny payment.

Keep in mind that's all just a bunch of "I think." To know for sure, call your provider.

[Arley 0]

Also, one of the main reasons for having the patient lose the 10% is to shrink the fat on your liver so that the surgery will be safer. That is what my surgeon says and so do many, many others.

[Talyn 0]

Kaykay

The best advice is to find out exactly what your insurance company means. You could spend all day second guessing and wasting valuable time. find out what you need to know/do and then refocus.

As a recently banded patient and an RN, who happens to work for a managed care company I wanted to put in my two cents worth. Losing the 10% should not be an issue, my surgeon required a liquid diet to shrink the liver prior to sugery, during which I lost 20 lbs in about 10 days. The diet restricted me to I think 10 grams Protein a day and less than 700 calories. It gave me an excellent "jump start" and showed that I could lose weight. Depending on how much weight you need to lose, the liquid diet phase may be extended. If so , you gain tthe advangate of more weight loss and therefore a lbigger edge.

:whoo:Hope this helps.

T

[AIvie 0]

I also have bcbs of tn they denied me the first time because I hadn't lost 10% of my body weight. I had 6 months to appeal and they said if I lose that 10% by then they will pay and they did. to lose it quickly I went to my pcp for the supervised weight loss and I filled the bottom of my purse with pennys for the first visit my purse wieghed 11 pounds so I immediatly lost 11 pounds. It took me 4 months to lose the rest and then they paid. I hate that insurance company. Also I didn't quite lose the 10% only part of it but they still paid.