Bummed....a big DENIED....

[amlus 0]

:cursing: Ummmm, I just called that # and spoke with Brandi and the cash pay price is $14,100, which includes one year of follow-up care & adjustments, NOT $5,700. Didn't think that made much sense.....

[Moxi 0]

Well, I have a 12 month pre-existing clause on my insurance so they denied me because of this. In my fifth month of having this policy now. Also, at they also want a three-year BMI of over 40 and I have been 38-39 and over 41 for just the last year. No major comorbidities......So, I can go self-pay or wait 1-2years MORE. I have already waited almost a year for this......thinking I will head to Colorado....SO BUMMED because I am ready for this NOW....

My insurance has a 5 year BMI over 40 clause. Althoug I am at 40 now, like you over the past 5 yrs I was only in the high 30's. I was super worried about them denying me for this. I got got medical necessity/support letters from a couple Dr's and even considered (but didn't) sending a letter myself. They are covering my surgery. So don't give up hope. When your time comes around again, get some letters from your doctors.

I looked into the self pay at the hospital I am getting my surgery at and it's $20K!! The hospital expenses alone (without the surgeon or cost of band itself) is 13 or 14K.

[SarahMarie83 0]

Hello, I work for BCBS here in IL and have some advice for you. About the pre-existing clause - if you had insurance coverage prior to your current plan then you may be able to get that waived. Call your insurance carrier and find out if that's a possibility for you. Also find out if your BMI has to be 40+ for the entire 3 years or just at time of surgery. Ask if you can look up the Medical Policy used to deny you online or if they will provide you something in writing so you and your doctor have a finite list of exactly what you need. If all else fails, there's always the appeals process and they are generally reviewed outside of the strict policy based on true medical necessity. Don't give up hope just yet! Call your insurance company and find someone who is willing to take the time to help you and get the answers that you need. If you can afford it, by all means go with self pay....but very few of us are that position so I would recommend doing all you can to get it covered under your insurance. Hope this helps!

[MSLAbanding 0]

yes they are real doctors. i know quite a few people that have had the surgery and lost all their weight with these doctors. they are very well known. they care about their patients and are not in it for the money. they have their private practice and they also do the lap band surgeries. why don't you look them up on the internet. I am sure you can find info on them. i was just trying to give you some information that I thought might help you. I would not go to Mexico for my surgery. if you read my e-mail i live in Hattiesburg MS and I went to Houma LA to have my surgery done. they did an excellent job and I am on my way to losing my weight. I have had two adjustments so far and I will be getting my third next week.

[MSLAbanding 0]

I don't know what Brandi you spoke with but before insurance my total was $5,700. I paid out of pocket $1,100 and my insurance paid the rest. I have the write-up in front of me that states "Cost of Procedure $5,700. Why would I make something like that up.

[amlus 0]

About the pre-existing clause - if you had insurance coverage prior to your current plan then you may be able to get that waived.

I had pre-existing coverage like 90 days before this plan went into effect. Iowa's law is you cannot go over like 66 days or they can hammer you with a 12 month per-existing condition clause. :crying:

Also find out if your BMI has to be 40+ for the entire 3 years or just at time of surgery.

It says in my health benefits document that "...You must have a Body Mass Index of at least 40 for at least three years..." I have none of the 5 major comorbidities they specifically count if your BMI is just greater than 35...yet. But, need a year of documentation even if I were to get one. Been tested for sleep apnea and don't have it. I guess I am thankful I don't have major comorbidities, but I am having back & knee issues and have a genetic history in family of Diabetes, both types.

Thank you so much for your help and input! I think my insurance should pay for this and am very sad that they won't......any other ideas are welcomed!:thumbup: