HELP!! Here is what I found on My Insurance Website under my plan. ???

[88Shelly88 0]

Well I looked up my plan (while I am still waiting to hear officially from my HR dept at work on if my Lap Band Surgery would be covered or not) but this is a VERY small protion of what I found? What do you think??

Medically necessary or medical necessity means the extent of services required to diagnose or treat a bodily injury or sickness which is known to be safe and effective by the majority of qualified practitioners who are licensed to diagnose or treat that bodily injury or sickness. Such services must be:

1. Performed in the least costly setting required by your condition;

2. Not provided primarily for the convenience of the patient or the qualified practitioner;

3. Appropriate for and consistent with your symptoms or diagnosis of the sickness or bodily injury under treatment;

4. Furnished for an appropriate duration and frequency in accordance with accepted medical practices, and which are appropriate for your symptoms, diagnosis, sickness or bodily injury; and

5. Substantiated by the records and documentation maintained by the provider of service.

Medicaremeans Title XVIII, Parts A and B of the Social Security Act, as enacted or amended.

Mental disordermeans a mental, nervous, or emotional disease or disorder of any type as classified in the Diagnostic and Statistical Manual of Mental Disorders, regardless of the cause or causes of the disease or disorder.

Morbid obesity means a body mass index (BMI) of 40 kilograms per mass squared or 100 pounds or more over your ideal weight as determined by the Metropolitan Life Height and Weight Tables for Men and Women, as of the date of service.

THIS IS LISTED UNDER TREATMENTS NOT COVERED UNDER PLAN:

31. Services for the treatment of obesity;that is not morbid obesity (clinically severe obesity);

I fall under the MORBID obesity as I am 5'1" and weigh 235, putting me at over a 43 BMI???

[Kristin0227 0]

Sounds to me that you will get approved as long as your BMI is over 40 and yours is so now you just have to jump threw the rest of the hoops to get the insurance to approve it!

Congrats

~Kristin~

[faithmd 14]

It *looks* like it should be covered, by why wait for HR to call you back? Call your insurance company (with your card in hand, or make sure you have them look up your specific policy number) and ask them yourself. That's what they are there for, make 'em work!

[88Shelly88 0]

I am soo scared to call and be let down I guess. When I did call they told me that if it was medically necessary it was covered. How does it work for fills, maint.,etc. Do they typically cover all of that if the surgery is covered as well? I can say that I work for a LARGE corporation and the HR person that I am working with is great, when I had my son and had questions on my bills that I could not get anywhere with the insurance company on, she went to bat for me. Thanks dear! ) PLEASE PRAY FOR ME. I need this surgery!!

[faithmd 14]

I am soo scared to call and be let down I guess. When I did call they told me that if it was medically necessary it was covered. How does it work for fills, maint.,etc. Do they typically cover all of that if the surgery is covered as well? I can say that I work for a LARGE corporation and the HR person that I am working with is great, when I had my son and had questions on my bills that I could not get anywhere with the insurance company on, she went to bat for me. Thanks dear! ) PLEASE PRAY FOR ME. I need this surgery!!

I will keep my fingers crossed for you!

But again, to know if they cover fills, et cetera, you need to talk to them. There is no way for me to know that, and there is no "typical" situation with insurance, sorry...

[Kristin0227 0]

Yes. Call your insurance directly it should only take a few minutes (in insurance time). But, if they already told you if it was med. ness. they would cover it, then I would find a Dr. and let them do the rest. Most insurance companies do not cover the fills and that is why you need to attend a meeting and get info from a doctor. They can tell you how much a fill/dr appointment is.