Stupid question... HELP!!

[Riane226 0]

Hi everyone! Thanks for taking the time to read this. I have a stupid question. I just started the whole process of trying to get a LAP-BAND, and Im not quite sure the order that things need to be done in. I know my insurance covers the proceedure, and I know that my insurance covers the surgeon that i have chosen. Bascially all i have done so far is go to my PCP and tell her that I want the proceedure done, and she told me that she believes I am a great canidate. I know that I need to meet with my surgeon, and I know that the surgeon requires a psych consult, but after that Im not sure what needs to be done. Im also not sure when the letter gets submitted to my insurance company for approval. My insurance in BCBS of NJ. From reading other peoples posts, Im guessing that i meet with the surgeon, get the psych consult, and the surgeon submits the letter for approval? I also need to know if my surgeon or the PCP is the one to submit the letter. Please someone let me know how this whole process works. I feel like I have learned so much from doing research and this site, but this is one question that really hasn't been answered.

1 more thing... when I called my insurance and asked them what was required for the surgery, all they told me was a letter of medical necessity. Im going to call back as soon as this is posted! :laugh:

Thanks for your help in advance!

PS- Sorry for the typos!

[TQUAD64 9]

Well I have Blue Shield of California. This is what they had me do. I placed it in the order for each step I had to complete.

1. Meet with my PC doc and get him to sign off on it
   
2. PC sent letter to insurance company stating it was medically necessary
   
3. Insurance company assigned me a case manager & approved me to see the pysch and nutritionist
   
4. Started seeing nutritionist for 6-months (once a month)
   
5. Saw the pysch guy and passed
   
6. PC submitted all paper work to insurance company showing that I did the pyshc and completed 6-months of nutrition classes. (August 2008)
   
7. Insurance Company approved me to see the surgeon
   
8. The surgeon would not meet me until I completed her requirements.
   
9. Orientation class
   
10. Nutrition class
    
11. Pre-op class
    
12. Then met with the surgeon
    
13. Then had an upper GI and HYplori test
    
14. Then was given a surgery date
    
15. Completed pre-surgery lab work and EKG
    
16. Surgery November 11, 2008
    

Good luck!

Edited January 1, 2009 by TQUAD64
Typo

[*slim* 2]

I have Blue Cross Blue Shield of Illinois. I had to do the following.

1.I went to a free seminar for the surgeon. They made my initial appointment there. 07/05/08

2.Met with my PCP for a letter of medical need.

3.Got proof that I followed a 6 month diet plan with my PCP within 2 years of applying for the surgery.

4.Meet the surgeon (they scheduled my nut visit and psych eval). 08/05/08

5.Pysch eval and Nut visit 08/11/08 and 08/12/08

6.All info submitted to insurance for approval. 08/19

7.Surgery date scheduled upon approval. 08/25/08

8.Pre-surgery class 09/03/08

9.Upper GI and lab work (within 2 weeks prior to surgery) 09/18/08

10.Surgery 09/25/08

Good luck!

[laurenica23 1]

I have BCBS of Indiana. Your surgeon's office should detail everything for you, but this is the gist of what I had to do.

- attended free seminar, set appt with surgeon

- met with surgeon, dietician, told to start 6 month supervised weight loss (1st class was this meeting)

- attended SWL classes for 4 months

- 6th class was last meeting with surgeon. met with surgeon, dietician again.

- got called for pre-op testing

- did pre-op testing

- did psych eval

- called about approval

- attended pre-op class

- had surgery!

[PATCHELTON 0]

Requirements will vary slightly from one surgeon or insurance to another. I have Blue Choice (HMO under Carefirst BC/BS of Maryland). Since I didn't have documentation of a 6 month diet, that is where I had to start. I met with the bariatric team's dietician and she set it up for me. During that time I had my consult with the surgeon, my psych consult, and I started going to the monthly support group meetings at the hospital where I would have my surgery.

--started 6 month supervised diet

--had surgeon consult(rec'd checklist of items to bring)

--had psych consult

--had stress test req by surgeon/echo req by PCP

--finished 6 month supervised diet

--saw surgeon again

--saw dietician for pre and post op dietary consult

--had pre-op class

--got surgical date

--pre-op liquid diet 2 wks before surg(this varies by patient)

--surgery

[Riane226 0]

I have BCBS of Indiana. Your surgeon's office should detail everything for you, but this is the gist of what I had to do.

- attended free seminar, set appt with surgeon

- met with surgeon, dietician, told to start 6 month supervised weight loss (1st class was this meeting)

- attended SWL classes for 4 months

- 6th class was last meeting with surgeon. met with surgeon, dietician again.

- got called for pre-op testing

- did pre-op testing

- did psych eval

- called about approval

- attended pre-op class

- had surgery!

Can you just tell me what SWL is? Sorry. Thanks!

[Riane226 0]

I have one more question... Can anyone tell me what they are looking for in the 6mo supervised diet? I have been on Phentermine for the last 19 months (no longer taking it now), and I had to go to the Drs once a month to have my BP and pulse checked and could only get the script if I physcially went to the doc. Think that may count? Thanks for your time again. Sorry to be a bother.

[TQUAD64 9]

I have one more question... Can anyone tell me what they are looking for in the 6mo supervised diet? I have been on Phentermine for the last 19 months (no longer taking it now), and I had to go to the Drs once a month to have my BP and pulse checked and could only get the script if I physcially went to the doc. Think that may count? Thanks for your time again. Sorry to be a bother.

They are looking for what you described. Meeting with the doctor or nutritionist at least once a month, being weighed in, and doctors or nutritionist's notes on weight loss.

I saw my nutritionist and/or my doctor; who ever I could fit into my schedule. They would weigh me and ask how I was doing. They would ask me about exercise and make notes about my exercise. We always discussed the gastric banding procedure and that was documented as well. All the notes/documentation were faxed to the insurance company.

[Riane226 0]

Thanks TQUAD64, PATCHELTON, laurenica23, and slim-n-tn for your help! I found out today that my Surgeon requires a meeting with them and a support group meeting, physical exam, blood work, EKG, chest xray, and psych eval.. They also recommend getting the weight loss history together for insurance purposes. After all that is completed they submit the paper work to the insurance. Once its been aproved you get a surgery date! Im hoping my almost 2 years on Phentermine (the he!! pill!!) will be counted at a 6 month supervised diet. I guess my next step is meeting with my surgeon... im assuming i just need a refferal from my PCP?

:Yawn: HAPPY NEW YEAR!!! :thumbup:

[whatakindgirl 0]

It is different for each insurance carrier and specific healthcare plan. i.e. Blue Shield HMO requirements are as long as you attend a 6 month weight management program.... Aetna requires 5 years of documented PCP visits for morbid obesity and a 6 month weight management program. Make sure to call your insurance provider (ISP).

Here was my steps and I had Blue Shields HMO:

1. Get PCP approval and referral to insurance approved Weight Management Program.

2. Completed a 6 month Weight Management Program. One appointment a month, 6 months consecutively.

3. Completed Blood work and psych evaluation. Weight Management group submitted paperwork to my Insurance for approval to have 1st consult with Surgeon.

4. Set up and had 1st consult appointment with Surgeon.

5. Surgeon office determined I was ready for the procedure and submitted paperwork to my Insurance carrier to have surgery approved.

6. Pre Op appointment and Surgery dates set up after approval received from my insurance carrier.

7. Finished Pre op blood work, x-rays, and EKG.

8. Surgery... Whooo woooo!

[FatRuby 0]

Hi TQUAD64,

I'm starting the process with meeting my surgeon next week. I see that you are from California too, where did you get banded?