BC/BS Michigan PPO - Individual Plan

[tripletmomma2000 3]

Hi all,

I am brand new to this forum... though obviously, not new to weight management (and failure thereof!)

I *finally* made the 7-year in the making decision to get a Lap-Band. All things considered, this is the correct WLS for me.

Here's my stats:

F/41

Ht: 5'6"

Wt: 350

BMI: 56.5

I have struggled, on the "books" with my weight, since about 1980. So... past medical history is with me.

I've been over 300# for about 13 years.

I decided to go and see a Surgeon in my area that came highly recommended. He does 2-3 Lap-Bands/week, and actually has a band himself.

When I went in for a consultation, I presented my Insurance Card, which is BC/BS Mi PPO, and the office staff assured me that everything would be covered, because I meet all the requirements.

Apparently, however, this applies to the same plan with GROUP coverage. I have INDIVIDUAL coverage. The individual policy does not cover.

My surgeon's office is filing an appeal for medical necessity, and I sent in a 3-page personal medical history, including all of my ailments, meds., etc.

Unrelated: I am currently having serious pain in my pelvis. I have had an ultrasound and a CT scan. The ultrasound came up with nothing. The CT scan didn't show any problems in my pelvis; however, it does show a lesion on my spleen... too large to be a cyst, and I've been referred to a general surgeon for further evaluation.. read: surgery + biopsy.

My Lap-Band surgeon of choice is a General Surgeon. He agreed to do the biopsy of my spleen while he does the lap-band.

I asked the doctor's assistant if we could do the spleen (possibly spleenectomy?) as a covered procedure, and I'd pay the lap-band OOP... she said "perhaps" and that it would be about $5200.00.

So... this is where I sit. Because I was under the impression that I covered, I had the pysch eval, and am in the midst of having sleep study (totally have sleep apnea!) and a cardiac clearance. The bills haven't started rolling in.... yet.

I'm looking for any advice I can get at this point. I've waited myself out for 7 years making this decision..... I honestly don't want to wait 5 more minutes to get this rolling.

Thanks for listening,

Karen