Maybe i can help :)

[CarmenPonce 0]

I am a Health Insurance Broker and a fellow banster. If you have insurance questions I will try to help. Just know with so many carriers:eek: and many more plans:eek::wub: ( i.e. Individual, Small Group, Large Group, Riders, and Exclusions) I will not know what the specifics of your plan are, but I can help you to navigate the nightmarish rollercoaster that is insurance.

[BethL 0]

I have Aetna PPO and am completing the 3 month supervised diet. I'm getting conflicting reports on whether I need to go see my doctor once a month or twice a month for the 3 months. Initially I was told monthly visits with the doctor. Then today I met with my surgeon and they said it needs to be two visits with the doctor each month for the 3 months.

[CarmenPonce 0]

Beth,

I do think listening to your surgeon in this case maybe helpful to in getting enough data to Aetna, even though you may only need to do monthly visits, bi-monthly visits will be better.

But when in doubt you can contact Member Services (there number should be on the back of your card but if not let me know and I will get it for you) and ask them explain in detail how many visits are need to within the 3 month supervised diet to satisfy there requirements. Also while on the phone with member services see if they can mail you a full explanation of your benefits not just the summary. You should (if you have not already) sign up on Aetna’s web site http://www.aetna.com/index.htm. There you should be able to review your plan benefits and check claims.

I hope this has been helpful to you :redface:

[skinnydesires 0]

I have a question for you:smile: Before starting this process I had called my insurance company(UniCare) several times to see if the lapband was covered. I got a couple people saying yes and a couple saying no. I finally had someone fax me any exlusions I had since my policy papers at home included nothing about bariatric surgery. This is what was faxed to me:

GENERAL MEDICAL EXCLUSIONS:

Treatment for obesity or services performed primarily for weightloss or control(including gastric bypass and gastric staplings): but this shall not exclude procedures that are necessary due to a specific condition caused by another illness or for morbid obesity as determined by the plan.

So by the sounds of it, as long as I am morbidly obese, it should be covered. This is how my bariatric center read it also. Am I reading it wrong?

I was denied a few weeks ago with the reason that it is not a covered benefit but nobody has been able to give me anything that shows where it is not covered. I just faxed an appeals letter today.

Am I chasing something that just isnt going to happen???:redface:

[CarmenPonce 0]

Skinnydesires,

Yes, it seems by the way your exclusion is written they would cover your WLS but here are a few points…

• The exclusion as written is “but this shall not exclude procedures that are necessary due to a specific condition caused by another illness or for morbid obesity as determined by the plan.” The key terminology is “as determined by the plan”. Most carriers require you have at least a 35bmi with 2 or more co-morbidities or a 40bmi without. So you really need to find out what your plan states as morbid obesity and do you meet there criteria.
  
• The doctor needs to be very specific when writing your Letter of Medical Necessity to your health carrier. Outlining the issues with your health which have been affected by your obesity. The letter would be helpful if backed up by medical documentation. Also it is a good idea for to ask your doctor if you could have a copy of the Letter of Medical Necessity. You should submit the letter along with your appeal.
  
• A little known process with the carriers is to also file a grievance. This should be done after your claim has been denied multiple times. A grievance is different than a claim denial in that it does not go to the claims/approval department but to a higher up corporate level and should raise some eyebrows. When you file a grievance it is sent to the carrier corporate level but also the state insurance department. At the state level your grievance will be logged against the carrier. You see all insurance carriers have a rating, and one of the ways they get there ratings is on claims handling. It is really important for the carriers to keep there rating good.
  

I know it is frustrating now but persist and I’m sure you will get your approval. I hop this has been helpful to you

[skinnydesires 0]

Thank you sooo much for taking the time to answer my question. Your opinion and knowledge gives me hope. I was denied a couple weeks ago and I took a break to think about appealing it. Now I have new hope and will go full force to try and fight their decision.

I have reviewed UniCares policy on morbid obesity and qualifications for surgery and I definitely qualify. The doctor had written a wonderful letter of Medical Necessity which I do have in my hands and will forward again to the insurance company with my appeals letter. And thank you for the info on the grievance process. I will definitely go that route if necessary. I think UniCare is just hoping people will stop fighting after the first denial. They are dealing with the wrong girl:biggrin:

Thanks~Debbie

[rachl24 0]

I am a Health Insurance Broker and a fellow banster. If you have insurance questions I will try to help. Just know with so many carriers:eek: and many more plans:eek::confused: ( i.e. Individual, Small Group, Large Group, Riders, and Exclusions) I will not know what the specifics of your plan are, but I can help you to navigate the nightmarish rollercoaster that is insurance.

I have Benefits administered by UMR, Which is Open access to Great West Healthcare. My companies Benefits summary state the following :

Gastric or intestinal bypasses.

• Charges for diagnostic services.

For surgical treatment of Morbid Obesity the patient must be:

• Twice his ideal weight;

• Demonstrate inability to control weight through diet over a minimum of a five-year period

documented by a Physician’s medical records; and

• Must suffer from a documented separate condition which is aggravated by obesity

I just had an RN from Greatwest tell me that it "looks" like my plicy only covers Gastric Bypass and not the lapband.. Should I contact my company administrator or appeal this.. It makes no sense that they would cover Gastric Bypass and NOT the lap band.. Any advice would be much appreciated..

[CarmenPonce 0]

I would contact Member Services for your Health carrier. The phone number is usually located on the back of your card.

You need to remember that the LapBand is still a fairly new procedure here in the US (only 9 years, I think). When the wording for your policy was drafted it is likely that LapBand wasn’t even and option at that time. So in this instance it may be covered.

I am here to help you if you need.

[Dixieland 0]

I also have aetna PPO, and was told I had to have a 6 month supervised diet before getting the lap band surgery? How did you get a 3 months diet plan? I would appreciate your answer. Thanks

[CarmenPonce 0]

Here are a few of the Aetna PPO plans, do you have one of these?

MC $10,000 100 / 50

MC $1000 70 / 50

MC $1000 80 / 50 / 50

MC $2000 80 / 50 / 50

MC $250 80 / 60

MC $250 90 / 70

MC $2500 75 / 50

MC $500 80 / 60

MC $750 80 / 50 / 50

MC Basic

Open Choice Out of State/Situs High PPO Plan $250

Open Choice Out of State/Situs Low PPO Plan $1000

Open Choice Out of State/Situs Medium PPO Plan $500

PPO $500 90 / 70

PPO $750 80 / 60

[queenlil09 1]

Y'all are so lucky. When I got my surgery done 5 years ago, it was very rare for it to be covered, and my insurance at the time, United Health Care, did not cover it at all.

I have a few questions for you. I am just graduating college and I need to get a temporary insurance plan until I start working in January (taking some time off). Will I have a problem getting a plan because I have a lap-band? And while we're on the subject, where do I start looking for a temporary plan?

Thanks Carmen!

[kajunlady38 0]

Hi Carmen ..i have bcbs alabama..all my paperwork was sent in and they required a 6 month diet with pcp. which was done the also need proof of weight history for yrs 2006 2007 2008....i dont have that because i never go to the dr and when i do i beg not to weigh ..lol so they said i can send pictures but once again i hide from the camera so my pictures are very limited do you think that will be a problem for me. also my bmi is somewhere in the 60's ...:thumbdown:....thanks

[CarmenPonce 0]

queenlil09,

I have pasted a link for you to get some quotes for your individual health insurance. Individual health insurance is on a month to month basis, so you can stop at any time. As far as being denied due to your previous lapband surgery, I don’t think that they will deny you coverage for this but they may increase you premium and/or exclude preexisting conditions i.e. lapband

http://www.ehealthinsurance.com/ehi/Alliance?allid=Yah26044&sid=tlp

Generally, the rates shown in the quotes are "standard" rates for enrollees without any medical history that fall within the underwriting guidelines. Insurance rates are also based on age and residence zip code and medical history.

The rates quoted are "standard" published rates for enrollees with no medical history.

Enrollment will be based on the medical information included on the enrollment application.

Enrollees without any medical history will be approved with the "Standard" published rates in this quote. If any medical risk exists, determined by the underwriting department and based on medical records, they can increase the monthly rate 10% to 75% per month.

[Soon2B2LittleE 21]

"I am a Health Insurance Broker and a fellow banster. If you have insurance questions I will try to help. Just know with so many carriers:eek: and many more plans:eek::biggrin: ( i.e. Individual, Small Group, Large Group, Riders, and Exclusions) I will not know what the specifics of your plan are, but I can help you to navigate the nightmarish rollercoaster that is insurance."

Hi,

I have BCBS of Alabama and started my 6 month supervised diet in January of this year (the end of January actually) and was going at the end of every month (about 30 to 31 days apart). At the end of June, my doctor was on vacation and the office was closed so my next appointment wasn't until the first week in July. My question is, will I have to start over since, technically, I missed the month of June, although I picked back up a few days later in July (my doctor considers this my next visit)? My other appointments resumed during the first week of each month there after (30 to 31 days apart). I am nervous because I don't want to start over or pick up from July; then that would be the second time I would have been set back because of dates. HELP:confused:

[tt1 0]

I am a Health Insurance Broker and a fellow banster. If you have insurance questions I will try to help. Just know with so many carriers:eek: and many more plans:eek::biggrin: ( i.e. Individual, Small Group, Large Group, Riders, and Exclusions) I will not know what the specifics of your plan are, but I can help you to navigate the nightmarish rollercoaster that is insurance.

I posted a question on here earlier today regarding tricare prime (north) about the way they calculate the 200% over ideal weight. I have seen on here were triwest just adds 100 pounds to the ideal weight on the weight chart but someone else said they double the ideal weight. Do you by any chance know how they calculate it?

thanks