Lap Band Not Covered???

[kat72 0]

I attended a weight loss support group meeting yesterday. The surgeon who performs the band as well as RNY led the discussion. Afterwards, I asked him if he had any patients who were covered for lap band through Pacificare, and he told me yes. I explained to him that I have Pacificare, but the band is not covered, only RNY, and he told me that the problem does not lie with my insurance company, but with my employer. More than likely, my employer purchased a less expensive 'package' from Pacificare that does not cover the band. I was not able to ask him what to do about this problem, because so many others wanted to ask him questions. I have an appt. with him on the 22nd of this month, but I just wanted to know if anyone here is familiar with what the surgeon told me. Does this mean that I would have to contact and discuss my individual case/needs with my employer through the benefits dept. or does this mean that if my employees benefit package does not include coverage for the band that I simply can't have it unless I self pay or change my insurance carrier? I would hate to leave Pacificare, because all of my other coverages are AWESOME!!! But, from what I've been told, Kaiser DOES cover the lap band, and what happens if I am told that I could either have the RNY or nothing at all?! I don't know that I would be emotionally capable of handling that answer. Any help/advice would be GREATLY appreciated. THANX!!!

[giveyouthemoon 4]

When I went to get my band, Kaiser did not cover it, only RNY. I understand that in some locations Kaiser is starting to cover it. I wasn't willing to wait. I did self pay.

I don't know the answer about who you need to appeal to. I'd start talking to your dr's office and to your insurance reps and to your HR reps to find what path you need to take.

Luck! Strength! And don't compromise. If you want a band don't settle for a RNY.

[DeLarla 22]

Fight it with all you got. If you have health problems due to your weight, appeal, appeal, appeal. People can and do win.

[HotLikeHer 0]

Call them and find out the reason it is not covered, it may be that particular one thinks it is "experimental" or you got some one that didnt look at updated info. At first I was told that it was experimental by Empire BCBS, then I talked to an actual nurse case manager one of the ones that approves or denies claims and got all the help I needed. I opened up my own case and then got the ball rolling on my own, I think it helped my Dr's office out quite a bit. As they didnt have to do hardly any calling back and forth...so I guess it saved them time to help others out that may have needed more attention...

Good luck

[kat72 0]

Thanx so much for all of the info.!!! I do not have any health problems-YET!!! Right now I am just overweight, but that is what makes me wonder...will it not be covered because I do not yet have any health problems related to being overweight? I don't mean to be a bugger, it's just that I am so afraid that if I request the band, I will be denied, and it FREAKS me out!!!

[Alexandra 55]

Kat, you need to speak with someone at Pacificare who is familiar with YOUR policy. Your employer may have carved out some benefits, but it's unlikely that the band is carved out specifically. More likely, your employer may have excluded all treatment for obesity/morbid obesity. If that's the case, you're probably up against a big problem.

IF, however, you are looking at Pacificare's OWN rules regarding RNY vs. band, you'll have lots of grounds for appeal if you're denied the first time. First of all, qualifying medically for bariatric surgery is the same no matter which surgery you may be having. If you're medically eligible for RNY, you're medically eligible for banding. (Do you know what your BMI is? If it's 40 or more, bariatric surgery is medically indicated. If it's less than 40, then you will need to show related medical conditions to support your request.) So qualifying medically is step 1.

IF the carrier (Pacificare) approves one procedure over the other--as many still do--you can appeal that depending on what their denial says. If it's a pro-forma denial because the band is "experimental" you argue against that in one way. If they say one is medically preferable, you argue that in another way. You just have to wait to see what their objection actually is before you argue with them.

[thinkthin 0]

I agree with Alex's guidance. Ask Pacificare to fax to you the medical necessity criteria for Bariatric Surgery. Apart from the criteria for the patient to meet (BMI, health issues, etc.) my insurance company (Oxford) also had specific guidelines for the MD performing Lap Band Surgery. In fact, the MD criteria was more extensive than the patient's for approval. Pacificare may not have Lap Band as an option only because they have yet to design the criteria for the MDs performing the surgery as well since it is newer, etc. I agree . . . explore every angle from your insurance company to your health benefits administrator at your company to get all the infomation you can to make your case! Good Luck!!!

[kat72 0]

Alex and Thinkthin, thanx for the info. as well as the encouragement. Alex, as of 8 weeks ago, my BMI was 43.7. However, I have been losing weight since then, so I am not quite sure what it is now, but I am sure that I still qualify for bariatric surgery. Treatment for obesity is not excluded from my plan. I was told that weight loss surgery IS covered through my plan. However, only the RNY or the vertical band. This is wherein lies my problem; I would like to avoid the RNY if at all possible. I've been hearing some horror stories! I would love to know how 'whoever is in charge' makes the decision that I get an RNY, vertical banding, or nothing at all. Is this decision based on the fact that I have an HMO? Is it because the band is still considered experimental? The band is no longer considered 'experimental' by the FDA, right? Does the insurance company also have the authority to decide if the band is experimental? As far as speaking with someone at Pacificare who is familiar with my particular plan, every time I call (I have called several times), I have been told that they do not have 'that' information. I'm thinking to myself, then what in the hell is the purpose of your job if you can't answer any of my f-ing questions? I have gotten so discouraged when speaking with them that I don't call anymore. If I do, it might get really UGLY!!! Now that I am done venting, I'd like to say thanx again, and I will try to call Pacificare to ask them some questions regarding my particular policy when I cool off.

[Alexandra 55]

I would love to know how 'whoever is in charge' makes the decision that I get an RNY, vertical banding, or nothing at all. Is this decision based on the fact that I have an HMO? Is it because the band is still considered experimental? The band is no longer considered 'experimental' by the FDA, right? Does the insurance company also have the authority to decide if the band is experimental?

This is EXACTLY what I faced when I was seeking approval. The fact is that it is within the carrier's rights to decide whether a certain procedure will be covered treatment for a given condition. The decision is not based on your having an HMO; it's a broad determination across all their medical plans that covered procedure A is the "preferred" procedure as treatment for covered condition X. All other procedures for the condition are just not on their preferred list.

If they (and by "they" I mean the medical policies department at Pacificare) receive a request for this procedure and deny it, you MUST be told why they are denying it. They have no obligation, however, to fill you in beforehand about why something is not on their preferred list. (That's so they can't be accused of making your medical decisions for you--yeah, right.) They aren't deciding which procedure you can have--they're only deciding which they will pay for, and while we know that in practical terms that is the same thing, it's legally not the same at all.

Carriers are not required to accept all new procedures or drugs as covered as soon as they're approved by the FDA. They want to see a body of experience first, and that means most carriers watch carefully to see how some new procedure works in the real world. I've seen banding be accepted slowly across the insurance universe, but some are still clinging to the "experimental" label even four years after FDA approval. This is why I was initially rejected, and what I managed to overturn on external appeal.

So don't give up!! You will never know the precise reason until your doctor submits a request for precertification. You may even be approved! So give it a whirl, and let us know how it comes out. If you need to appeal we can help you with that when the time comes. Good luck!!

[kat72 0]

Alex, your words are sooooo encouraging. I took your earlier advice and decided to call my insurance co. one more time to ask about my specific policy. I was finally able to speak to someone who was actually able to give me some meaningful info. I explained that I was interested in WLS surgery, but I had been told that only RNY or the vertical band was covered, and I was not interested in RNY. I did not want to 'waste' my time going through all of the pre-surgery stuff only to be told that the lap band is not covered. She kept me on hold for about 10 mins. and had some pretty good info. for me when she returned to the line. She explained that if the surgeon were to request that I have the lap band, my medical group (Scripps) would then review his request as well as my medical history. If I meet the 'criteria'/'requirements' and the medical group deems it to be a necessary procedure, then they approve whether or not it is to be covered. I made sure to get the name and badge number of the woman I spoke to. It has taken me over a month and several phone calls to get this small but necessary piece of info. I don't understand why I could not have been told this before. I know that this is not a definite yes, but it sure beats what I was told earlier, that the lap band was not covered at all.

[Alexandra 55]

You go for it and we're pulling for you. Lots of people are afraid to try because they're afraid to get turned down, but the fact is you'll never know if you don't try. Claims are never determined before the fact, and no carrier will ever say they are definite about something. It's all about the specific request and how it is submitted.

But it sounds like you got good information and are on your way. Fingers crossed!!

[auntnettie 0]

Oh my God, this sounds exactly like my ins. nightmare!! I am in LA and my company outsources their HR dept. to a company called Administaff who provides us with health Ins. 3 choices:

Pacificare PPO

Pacificare HMO

Kaiser HMO

Last year I had Pacificare PPO, should be the top of the line ins., right???

NO! I went to my GP and he put me on Phen and Pacificare denied to pay the whole office visit. THEY COVER NOTHING RELATING TO WEIGHT LOSS - That is thanks to the "cheap" policy that Administaff buys in bulk.

So I call Kaiser, they said Yes you should switch we cover all "bariatric surgeries".

I wait until open enrollment, switch to Kaiser and I hear Lap Band? Oh no, we define bariatric surgery as RNY. You qualify for that. Hell no! That is not for me!!

P.S. - 2 appeals later, I gave up. I have a 10/7 surgery date in TJ with Dr. Ortiz.

Ins. companies know how to play the game! They know they can break the average person. It takes a much stronger person than me to fight their system. I spent hours, days, weeks, months for nothing!!

I wish you better luck than me. I know it is possible. Go for it!!!

[Alexandra 55]

Auntnettie, that sounds like a real hassle, but because you tried you may have helped make it easier for some future bandster to get approved. So thank you for trying. That thought is what kept me going through the nine months and three appeals it took for me to get my request approved, and ultimately I won. So sometimes it CAN be done!

The bottom line is, you'll never know if you don't try. And the more the carriers hear from doctors who have patients needing this surgery, the more likely the industry will be to find ways to adopt it in the long run. I know that sounds counterintuitive, but it's true, especially when this procedure is proven safer long-term than RNY.

[DrHekier 0]

Unfortunately we have found that several insurance plans will only cover the Roux en Y gastric bypass and not the Lap Band.

Makes no sense to me.

Let's see, one operation has a 10 - 100 times higher incidence of death, a longer hospital stay, is more expensive, and results in a permanent re-routing of the GI tract that can lead to nutritional deficiencies and other problems requiring surgery in the future. Let's cover that one!

Some routes to fight your insurance company include: appeals, you or your surgeon speaking with the medical director at the insurance company, law firms specializing in obeisty discrimination e.g. www.obesitylaw.com, your state's insurance commision.

Good luck!

[kat72 0]

Dr. hekier, thanx so much for your input. It is greatly appreciated!!! I also wanted to ask you: If a person is overweight with no health problems, what are the chances of ins. not covering WLS, especially the lap band?