am I wasting my time applying?

[pistol1994 0]

I have blue cross blue shield of alabama for insurance. I have already checked and they do cover lap band with this criteria:

1) Complete BMI

2) Medical records for 3 yrs.

3) Medical records must document a medicallly supervised weight loss program. At least one attempt during one (1) year prior to the request and documented participation in the approved weight loss program for six (6) consecutive months.

4)No smoking

5) obesity for 3 yrs.

My problem is: I meet the criteria in every way but the 6 month weight loss program I only went in to get weighed 2 times within the first 7 weeks. From my understanding it has be be 6 consecutive months meaning every month. Am I wasting my time and effort even trying to submit all this? I really want this done but I cannot afford it out of pocket even with carecredit. If anyone has suggestions or help to face a denial please let me know.

Thanks!

Crystal

kimandcrystal@aol.com

[MacMadame 81]

I think you need to go in every month and they are strict about what the doctor's notes have to say too. You have to talk about diet *and* exercise. That gets a lot of people. The doc only puts down diet and not exercise.

But call your insurance and make sure. They are all a little bit different.

[JamieNP 20]

Start now and the 6 months will go by fast!

[pistol1994 0]

I was thinking that as well. I'm just going to start going in to the doctor now so in 6 months I can get it done.

Thanks!

Crystal

[JamieNP 20]

In the mean time, do all of the other necessary stuff. Go to an informational meeting, go to support groups, get your psy eval done if you need one.

[Cocoabean 430]

You can try to appeal the 6 month requirement. I successfully appealed it.

In my letter I stated my past attempts with weight lost and regained. I had Weight Watchers records and diary entries.

Also, the NIH does not recommend a 6 month program in their consensus:

The National Institutes of Health (NIH) Consensus Development Program: Gastrointestinal Surgery for Severe Obesity

I quoted that in my letter.

Best wishes,

Denise

[MacMadame 81]

In CA, if you have an HMO, the DMHC will overturn the requirement to do the 6 month diet if you appeal up through them. They agree that there is no data to support this requirement.

[pistol1994 0]

I am in Idaho if that helps.

I'm going to do the psych evaluation and pre op appt this week and then they will submit everything for me . The secretary stated that if we get denied she will keep appealing. I have an appt with a weight loss doctor on Tuesday too to start the 6 month plan just in case I need to wait. Thanks for all your help and if I could get any sample letters to help my appeal I would appreciate it.

Also I started the weight loss thing about 8 months ago but went in to get weighed only 2 times. I am heavier now so if I could prove that it didn't work for me.

[Band_Groupie 3]

Pistol- Just wanted to mention that I have BCBS, but in PA (every state/even area is different for BCBS). But something to ask since you mentioned pre op testing/psych etc. I was clearly told that my BCBS will not accept any pre op testing requirements done more than 6 mo. out FROM THE SURGERY DATE (if it's longer you have to pay to get them redone). Surgery will generally not come immediately at the end of your 6 mo. diet so add a month or two at least for approval process/possible complications. They told us to wait at least until you've done 2 mo. of the diet to start these. Just a heads up and good luck with your start!