Need Help to Get Insurance Approval for Lap Band as a Treatment for Diabetes

Sooner · June 7, 2008

I am hoping to hear from other type 2 diabetics who have had to take on their insurance company to get approval for a lap band as a treatment option for their diabetes. The latest literature in the medical journals for the past 2 years report that lap band surgery has been demonstrated to be a successful treatment option for diabetes, often doing away for the need for medications and reversing the complications of diabetes.

I have had diabetes for 9 years and I am needing to progressively take more medications to control my blood sugar as well as developing associated diabetes-related diseases. I am on 2 types of insulin (4 injections a day) and a diabetes pill twice a day. I also take 2 medications for high blood pressure, 1 pill a day for GERD, and use a C-PAP machine for sleep apnea every night. X-rays have verified that I have arthritis in my hips and I take 3 medications a day for depression. All of these problems are considered "co-morbidities" of excess weight and diabetes.

Because my BMI is 36.3, my insurance company, Cigna, has refused to approve my surgery request stating that my weight is borderline. They also have told me that I need to be on a 6 month doctor-supervised diet plan to demonstrate that I can lose weight.

Problem: If I do lose weight, I will no longer qualify for the surgery! Additionally, the latest medical research has shown that only 6% of people who go on a diet to lose weight maintain their weight loss for a year. It seems to be a waste of time to go through the diet regime -- I will still have diabetes and will likely be among the 94% of people who don't maintain their weight loss.

Any similar experiences out there or suggestions for how to get insurance approval?

Getting discouraged,

Sooner

Telecia · June 11, 2008

For me one of my arguments to my old doc (Start seeing a new in 2days!)

Was that I can't get as good control of my diabetes because I am so conditioned to eating large portions. And much of that is high carb stuff like bread, rice, Pasta, potatoes etc. cause its so much cheaper then the fresh veggies & high protien lean meats, I should be eating.

I have changed that somewhat. As much as I can at the moment. But till I can get the Portion Control size the band would allow the best I can do is try to keep reducing my meal sizes.

If your have complications due to the diabetes that alone should be reason enough to approve the surgery as some of the complications can be devistating. Worst cases of amputations or blindness come to mind.

Keep trying! Do you have any other specialist and or doctors that might also be able to assist in writing up needed documents? cardioligist or another doc for the sleep apnea? Is your sleep apnea treatment working well? Might be another thing to add to the document if its not working so hot. What about joint pain or mobility/balance problems?

Jack:
It is NOT the insurance carrier's job to tell YOU and your surgeon which procedure to choose. And if your PCP picks the right narrative to send, your BMI in light of your other co-morbidities, probably is not the real issue with the carrier.

Jacks right usually the insurance company has a set list of what has to be met other then the doctors recomendation. Have you called the company to see what these requirements are?

You might ask to see what letter your doctor is sending in and see about him/her modifying it. With any additional information you can find. I know others on this forum have posed example letters their docs have sent in maybe search for some to get ideas?

I have a BMI of 71 and couldn't get my PCP to approve the surgery shes totally ANTI-surgery. But my cardio & podiatrist are for it. So I changed doctors!! LOL now i'm hoping after 11 months of fighting with the anti-surgery witch I have a doctor who's at least concerned enough to talk about it.

Sooner · October 1, 2008

Howdy Sooner:
"Never give up, never give in. Never. Never. Never. Never."

so said Winston Churchill in the darkest hours of WW2.

Barely 45 months ago I was in a very similar spot as you. I was injecting 100 units Humulin twice a day, along with oral meds (15 years duration).

I was CPAPer for 10 years. My BMI was 47.5. Multiple co-morbidities.

Virtually impossible to lose weight....and my internist confirmed it...insulin, among other things...is a GROWTH hormone the way it acts. So I'm familiar with your distress.

All it takes is keeping nibbling away at the carrier's requirements.

It took 18 months for me from actual "MY" decision time surgery was my last hope, to the actual surgery itself, including being recertified a second time.

By the way, I was off injections and off CPAP at 11 months.

PostOp Life is GOOD.

You can do it. Oh, and the letter my internist wrote confirmed also that the open surgeries were too risky, as was the RnY they were trying to force me into doing.

It is NOT the insurance carrier's job to tell YOU and your surgeon which procedure to choose. And if your PCP picks the right narrative to send, your BMI in light of your other co-morbidities, probably is not the real issue with the carrier.

Also, I had to find a way to get them to authorize out-of-net provider.

You can do THAT too.

Cheers. Keep us posted.

Thanks for your great encouragement! The Obesity Law Firm appealed Cigna's denied and I got approved within the month! I'm scheduled for October 7th - just a week and a half after I received my approval.

Sunwyse · October 1, 2008

I only just found this thread. Congrats on getting their decision overturned. Seems crazy to me that they would deny you. Simple economics shows its cheaper for them in the long run to give you the op now.

In Australia, you can be approved as low BMI as 35 if you have a comorbidity. Diabetes is one of them.

So glad you will be able to go ahead and glad this post is here so others can see it, if they are having the same issue.