Insurance & Financing

Hi Everyone, I'm new to the forums and was looking for some advice. My doctors office sent in a letter of necessity recently and I have just recieved a denial letter from UHC. I'm now in the process of research and trying to determine how to appeal. Does anyone have any example letters to share? The letter specifically mentions they needed a 5 yr history of obesity, so I am in the process of contacting past doctors and trying to put an appeal package together. My BMI is 38-39, have several co-morbities (high blood pressure, high cholesterol and sleep apnea). I've done all the steps neccessary (tests, studies, 6 month diet program with nutritionist) and this is su…

Anybody on a individual insurance plan that has gotten approval for the VSG? If so, what insurance company?

Hi everyone, I self-paid for my surgery in July but was told by my insurance company that they would pay for it. Of course it is never that easy! I have to fill out the claim for myself as the surgeon I used charges a flat fee and does not deal with insurance. Any help or ideas? I have the CPT code for the lap-band surgery. Do I need to add a code for anesthesiology? Other ideas? I'm not even sure what to put in as charges since there was 1 flat fee paid. Any advice or anyone have the codes they used on hand? I appreciate any and all help. Thanks!!

My surgeon's office called me this week to let me know that they were resubmitting all my information to Anthem. They got an email from Anthem, informing them that they now cover the Sleeve as a stand alone surgery! They usually get word from Anthem within 2 weeks. I asked how far out she was scheduling surgeries and she said she just scheduled the first one for February. It's been a long wait and I had almost given up hope that I would ever get to have surgery. I'M SO HAPPY!!!

I just received a letter from the clinic stating that Tricare Primes require a 6 month documented "diet"..I have looked to see if any other post needed this but didn't see any. Did anyone else have to do this?

Hello all I haven't posted any questions on here but I have been reading for several months!! My paper work was submitted to my insurance, and I find out that they didn't approve it because I have to have 12 months of attempted weight loss but the dr who was going to do the vsg said bcbs only requires 3 months. So now I'm sad I was hoping to be scheduling my surgery. I've had an active membership at curves for 14 months and a 6 month doctor supervised diet so is there not anyway for my 14 months of working out to be my proof of attempted weight loss? Or do I have to do another 6 months of dieting and waiting? Any advice would help!!

Hello all...I am brand new here and have a question?? Anyone know if BCBS TRS Active Care 2 covers VGS?? I was approved for RNY but now I'm rethinking that and wanting to check on the sleeve. Any help would be much appreciated!!!

I don't know if this is the correct forum to place this question, but does anyone know, when you self-pay in the U.S., are you still required to meet minimum requirements to qualify for the surgery? You know the BMI, co-morbidites, psyc, pre-diet, etc... From the research I've been doing, seems Mexico doesn't require these things. Thanks for sharing your knowledge!

Well, I found out yesterday that my employer is changing insurance companies and the new company doesn't cover the VSG for someone with my BMI. It really makes no sense that riskier, more complicated, more expensive procedures get covered but my BMI has to be over 50 for the VSG. *facepalm* Anyway, after a few months of not being sure, it looks like I'll definitely be covering the cost of this on my own. I could probably try and appeal, but I really have no medically necessary reason to get the VSG over the other surgeries. It's just my own preference, so I'm doubtful any appeals would be successful. So I need to figure out how I'm going to pay for this. I have some …

Hi all, I was wondering if anyone has been able to get an insurance company to pay for banding if they say in their policy that they do not cover any bariatric procedures? I have Pacificare HMO and I have noticed that they have yo-yoed between years of covering and years of not covering this procedure. I currently had a doctor attempt an exploratory surgery and was unsuccesful due to my almost 300 pound body. I was hoping to finally do a lapband to only find out they are not covering any bariatric procedures and will not next year either. Not sure if there is any chances with fighting when the policy states they do not cover. When we spoke to them, they did say i…

I have UHC- empire plan. After visiting a number of surgeons, attending a plethora of wls support groups, I thought I finally found a wls surgeon that I wanted to proceed with. I went to my 1st mtg prepared with 6 month notes of weigh ins and diet attempts from my primary care dr. To my dismay and shock, the patient coordinator told me that the notes would not get me approved for the sleeve. This was perplexing as the notes indicate my health problems. I have done 1 year of weigh ins. the pc stated that I needed to detail food logs and nutrician plans and more information. this patient coordinator explained that I would have to do 6 month vistis with the nutritionist- bas…

I am active duty stationed overseas but my wife lives in Kennewick,Wa. She wants to get VSG but I have no idea if Tricare Prime covers it or not. I've been reading many forums and I'm getting mixed messages. Most say that tricare doesn't cover it and some say they only cover it at certain MTFs. If they do cover it what is our cost out of pocket? If they don't cover it does anybody know any good locations for us to get her surgery out of pocket? So far I've found hospitals in Mexico.

Hi, I was wondering if any of you can offer some advice/suggestions etc. I have been interested in the VSG for several months, I've been doing a medically supervised diet for a few months and have attended an info session with a surgeon in my area. My insurance does cover bariatric surgery however, I found out a few days ago that my employer has put an eclusion in our insurance coverage and will no longer cover any type of weight loss surgery beginning Jan 2011. No way , No how...there are zero ways around it. Needless to say i am totally devastated Sooo...I'm looking at self pay. I was given a "guesstimate" by a local surgeon for around 20k. Any one know of any Pa s…

I ve spoken with my insurance rep. and was told IEHP will cover the procedure after the six months of being on a weight loss program. I ve signed up for the program and its been at least 5 months and now registration form. i keep calling every 3 weeks to see whats up and they keep telling me they will send another one. still no forms. SO i am beginning to wonder if its on purpose. SO has anyone had the procedure done that has IEHP??

Hey everyone, I'm new here and just wanted to say hello I just applied for the Maryland Health Insurance Plan (it's our state high risk pool) because I keep getting denied private health insurance because of my weight. I was just wondering if anyone else here has the plan as well and has gotten approved for the lapband? I know it's a long shot but was just curious

Does anyone know if an insurance company... mine is Aetna... will FAX you an approval letter, if they say they have mailed it but nothing every arrived? My insurance company told me, on the phone, that my Sleeve was approved on Nov. 14th, and the letter was mailed out. But it has never arrived... and the doctor has not gotten their either. My surgery is supposed to be this coming Thursday, and all my tests, etc. are complete. I was wondering... has anybody heard of asking the insurance company to FAX you and/or your doc a copy of the letter that was supposedly sent? I believe that they are STALLING me, they have given me such a hard time already. Or would it be …

SO when I had my surgery, Tricare approved the procedure, the Dr post surgery follow up and 6 fills all before the surgery took place. Well I've had 1 fill so far so no big deal. The question is, after my 6 fills, will Tricare pay for any more? I have a 14cc band and the Dr only does 1cc at a time. I dont see how I could have good restriction on less then half a band. Maybe Ill be lucky but I dont know. Has anyone been approved for more then was initially approved?

Does anyone live in Ny and have Hip?? I work for the city and currently have GHI. However, as a single mom with 3 kids the co pays are killing me :blink: Im switching to Hip and that will take effect after the new year. I know 2 people that have Hip and were approved for a bypass. Has anyone that has Hip been approved?? Is there any special criteria?? I called Hip and the people acted like they had no idea what a lap band even was

I have hospital imdemity and short term disability from Aflac. I am reading tonight that they will pay 750 for a gastrectomy if medically necessary. Has anyone here had any luck getting Aflac to pay hospital or short term dsability.

I *finally* got through to someone today who actually did some research and discovered that it is indeed now a covered benefit. I don't know why I had such a hard time with that. Here is the policy that will tell you what the requirements are. It's a PDF file. http://manuals.tricare.osd.mil/index.cfm?fuseaction=TMAManuals.PVCSGetFile&PluginVersion=5&ReferenceManual=TP02&ReferenceChange=66&Type=ASOF&Manual=TP02&FileName=C4S13_2.PDF Good luck to everyone, and please...if you have already been approved please come back and tell us! I'd really like to know if Tricare is following those requirements to a "T" or if they are going on a case-by-ca…

Hi everyone, I've been a lurker for too long! My approval request was submitted to UHC on Tuesday 11/9 I'm trying to think positive thoughts. I'm so afraid it'll be 3 weeks before I hear from them and then they'll just want me to jump through more hoops! I have UHC Choice Plus PPO, I was told that my only requirements are whatever the surgeon requires from me. Let's hope that's the case. I know it's all set up by the employer, so there's really no way of knowing by all of us comparing notes. Keep your fingers crossed for me please! I'm really hoping to have my VSG before the end of the year.

I'm trying to get my finances in order so I can have VSG done in Feb/Mar 2011. I'm seeing cash prices listed, but it's as if the price if you have insurance is a BIG secret!! LOL! Maybe that isn't the case, but can anyone tell me what to expect price-wise? I'm hoping to use Dr. Nick in Dallas and I've BCBS Select PPO. Individual deductible of $630 and a family maximum at about $3500, plus an in-patient co-pay of $250. Then they cover 80% for bariatric surgeries. Also, what does that cover? I know I'll get more info from Dr. Nick's office soon, but I'm an info junkie! LOL! Thanks so much!! Dana

Today I received my first denial for lap band surgery. While I was told by friends to expect a denial the first time, I am disappointed. I thought I did everything correct. I am now going to appeal, but first just wondering what others experience has been with appeal and humana. The denial states "available documentation does not indicate that this patient has a primary care physician who has followed her pre-operatively, agrees that she should have the procedure performed, and will follow her post-operatively after procedure is performed." This to me sounds like maybe some information was not submitted to them. I did the 6 month supervised diet, and have the b…

Oh my! Okay...so I posted before, that I really do not think that my insurance will cover me. I am 5'8 3/4 and about 250-255lbs. My BMI goes back and forth between a 37-39 and the only comorbidities I have are: sciatic nerve pain, knee pain, and acid reflux. Nothing life threatening anyway. So, I found a doctor that will do the surgery with my comorbidities....for 5000 down and $200/month for two years. This includes 90 days of fills for free, and afterwards the fills are only $50. Great deal right?? Well, to qualify for this special you have to have the surgery BY 12/30/10. I KNOW I Want this surgery..I have been thinking about it for years....and know several pe…

Hi there, I have Anthem Blue Cross CA. I was wondering what 'steps' you have to take before your initial consult with the surgeon. I am attending the seminar Wednesday. Thanks for any help!

hello Everybody, i have Anthem Blue Cross PPO how fast will i get an answer weather they cover lapband or not? does anybody has any experience going through ANTHEM BLUE CROSS CALIFORNIA? thanks a million! :rolleyes2:

Okay this is what my insurance says (roughly-it wont let me copy and paste): -has to be 18 or older -clinical records support BMI of 40 (or 35-40 with life threating comorbidies) for a period of six months -documentation showing that you have had failure to lower BMI (within the past 12 months) following a doctors supervised medical progrom of 6 months or greater. -if those are met, then they will only cover it if surgery is done in a hospital that is certified as "well qualified" by the Center for Medicare and Medicaid. Our insurance is GEHA, a federal insurance. Basically, I am taking this to mean if I am above a 40...and stay fat for six months (and do the doctor…

I have Aetna Aexcel Plus Choice POS 2. I have been researching on Aetnas website about weight loss surgery and I still have a couple questions that some of you might be able to answer for me. First off, is there anyone here that has Aetna insurance and DID NOT have to do a medically supervised program for 3-6 months? I was reading on Aetnas website that you have a choice to do either the three month program or the six month program. Can someone please enlighten me that chose to do the three month program and what all they had to do? Thank you so much!

Does anyone know if Tricare Prime covers cost of fills after lapband surgery?

I've been reading a lot of posts about Tricare and their requirements, and a lot of the tests are things I've had done in the past. Does anyone know how recent your test results need to be? I had a sleep study about 3 years ago (have sleep apnea, use a CPAP), had fasting glucose done about a year ago, and EKG, ECG and 24 heart moniter over the summer (in July; had allergic reaction to new BP med), and am already scheduled to see a nutritionist and exercise physiologist on 11/15 (scheduled before I was interested in lap band surgery). From reading what others have said about Tricare in Montana, I really want to get the ball rolling; my PCM keeps going on vacation and I can…

Hi everyone, I am nervously awaiting the results of my inusrance company's review of my surgeon's request for me to be covered for a Veritcal Sleeve. I have an Aetna PPO coverage. My documentation is perfect, I have the nutritiionist, doc letters, comorbidities, pshychology letter, etc.... and my doctor and his assitant feel confident that I will be approved. More confident than I feel, anyway!!! My doctor participates in the Aetna PPO insurance plan, so we're all on the same team. But, in looking through the boards here. I noticed that somebody posted a message saying that "covered" with Aetna means that they will pay 80%. Not sure if this person meant "in network…

Hi! I am curious about the recent experiences with medicare and the banding. I have been on disability for 2 years and am Medicare eligible in Feb 2011. I am very excited about Medicare covering, since my husband's insurance refuses to have anything to do with any weight loss help. What have the experiences been and what can I expect? I so wish I could start the process now so I could have my surgery scheduled for Feb 1st! ~Thanks~ Bonnie

hey folks, I am a newbie here, and I have a question about the 5 year history. I have UHC, and they require a 5 year history for approval. Do you have to have been at the BMI rate of over 35 during that time? I lost a lot of weight (approx. 100 lbs) about 6 years ago, and gradually regained most of it over the last five years. Am I going to be penalized for this? I think my weight was something like 175 6 years ago (5 year history starts 6 years ago, go figure), and I am now at almost 300. Any idea?

I have recently started looking into getting lap-band® surgery. As stated in the title I have a BMI of 35, I’m not sure if what other problems I have would be considered a comorbidity. From what I can tell my insurance will cover the surgery with a BMI of 35 with one comorbidity. I am currently taking medication for Hypothyroidism, Low good cholesterol and depression….would any of these be considered a comorbidity? Thanks for any information you can give me!

Okay maybe I am making things way too complicated, but I just want to make sure I have all my bases covered. I had my first consult with my nutritionist today and I am sort of confused. I know I need to see my nutritionist once a month for three months. That's no problem. But what EXACTLY is she supposed to be documenting. I mean, is she supposed to weigh me as well??? Here is what Aetna's website says: a. Behavior modification program supervised by qualified professional b. consultation with a dietician or nutritionist c. Documentation in the medical record of the member's participation at each visit. (A physician's summary letter, without evidence of contemporaneo…

So it's that time of year where we get poked a lil harder for that weekly insurance premium because our insurance blows and we have to pay more and more each year. My question is, does anyone know of an individual plan with any insurance company that covers lapband. Sad to say, that is my goal to find an Insurance company that covers it and then I can drop my insurance at work! $62.00 a week for insurance is a little steep for not covering weight loss and after months of emailing back and forth to see if they would add the policy, they say no because it will cause our premiums to go higher....HELLOOOO!?!? Any guidance in the direction would be greatly appreciated. …

Has anyone been approved by Tricare with being less than 100 lbs overweight? I am about 85-90 lbs overweight with Sleep Apnea and High blood pressure (therefore I have my 2 comorbitities). Before I get started, I want to know if there is even a chance of getting approved. Thanks!!

Hi all One year out on my band and doing great. Unfortunate my wife and I both got laidoff in March. We are frantically searching for private health insurance. I have heard everything from they will not cover me at all... won't even accept the application! To a lifetime exclusion on the band and anything that goes with it... fills, slips, erosion. I found one company that will write a one year exclusion on the band and I started the paperwork for them. The alternative is COBRA which is three weeks of my unemployment check per month. Has anyone else had any success getting private health insurance and who did you go thru? Any help would be appreciated!

Hi! Just wondering, since I work for a small company that does not provide health insurance, I have to purchase it on my own. Does anyone know if self-pay insurance actually covers WLS? Seems like it's all company sponsored insurance that covers it. Thanks!!

I hate to be a whiner, and normally I accept when I'm defeated, but before I give up before I've even began I want to be SURE this is the end of the road with my thoughts of having LB done. I have Blue Cross Blue Shield of Texas. I just made a quick call to see what my coverage would be with lapband and was told point blank, (in a nice way!) that the procedure, nor any other obesity or morbid obesity treatment would never, ever be covered, at all. :thumbup: So is that it? Is there any way to protest when it's not that I was denied a particular procedure, but that they don't cover it, ever? I'm just so sad and deflated. Does anyone know what the procedure costs out o…

Let me share my story......On October 22, I was called by the Insurance specialist, at the Surgeons office that faxed all my paper work to BCBS of TN....she called to tell me that I had been approved for the surgery...I was all excited! She made an appt. for me to come in to see the surgeon and set my sugery date on the following Wed. October 27. On the same morning before I went to see the surgeon I checked the BCBS website to check the status of my Pre-Auth and it states that it is "Disallowed":scared2: and that was submitted on the 24th of October. I asked the IS if she was sure I was approved because of the online site and she was adament about the nurse over my case …

I have BC/BS of Alabama and have been denied because my weight for 2008 was just under what it needed to be to qualify. Has anyone else had this happen? The lady at my dr's office said she was going to appeal. How long does that process take? I am really anxious and don't want to wait any longer and will be devastated if I don't get approved!!!:thumbup:

I am shocked to say that my approval came in less than 24 hours! I had one final thing to do (get PCP letter to surgeon) and then - BAM! - approval! :huh2: :huh2: (ETA: The insurance woman from the hospital said that she has never seen an approval come through so quickly.) This seems like it went a little too easily, but I know how lucky I am that I am able to get this surgery covered by insurance. As of January 1st, my insurance is changing and, though surgery is covered, MY surgeon is not in their network. There is no way I want to start all over again, so I am glad to be having the surgery on 10-Nov-10!! Oh, I live in PA and my BMI was exactly 40 (no co-morb…

Hey - I just spent an hour reading through all the tricare posts so i'm hoping some one can answer this. Does tricare make you see a nutritionist for 6 months? are there any requirements that i should know about? · Is 100 pounds over ideal weight for height and bone structure and has one of these associated conditions: diabetes mellitus, hypertension, cholecystitis, narcolepsy, Pickwickian syndrome, hypothalamic disorders or severe arthritis of the weight-bearing joints · Is 200 percent or more over ideal weight for height and bone structure · Has had intestinal bypass or other surgery for obesity and because of complications, requires another surgery (taked…

I don't even know what to write to express how disappointed I am right now. Have gone through every required appointment including Upper GI, Endoscopy, 2 EKG' 2 sleep studies up though completing my pre-surgery admissions and was less than 36 hours from my scheduled surgery date at one point a couple weeks ago. The only thing missing was insurance approval. The surgeons office does not submit an insurance packet until a surgery date is set. With my date set at 3/31 I find out that they didn't submit the packet until 2 weeks prior. With me calling Aetna everyday to check the status and being told it is still under review I finally get a call from the surgeons offic…

hi everyone. i think i originally posted this in the wrong forum, so ill post it here now. i know alot of insurance companies dont cover the sleeve. my insurance company doesnt appear to have the new 2010 code 43775 for the sleeve in their system, but they do cover the duodenal switch code 43845, which is basically the sleeve with a bypass. has anyone here gotten the sleeve done by getting approved for the ds and then only having their dr do the first part of the ds, which is only the sleeve? im curious if getting only the sleeve done this way would work to get the insurance company to pay for it or even if the dr would be willing to do only the first part of the ds? also…

Hello all - anyone else have Government Employees Health Assoc. Insurance (Federal employees?) Just wondering how it has worked with them for anyone else. I called before I even went to see a doc 6 months ago to make sure the procedure is covered - it is. My doc submitted on 1/14/08. Office already told me to make some calls starting next week - that I will have more success than they would. Thankfully, my docs office is proving to be really helpful. I was a little worried with some of the stories some of you have endured. I will keep everyone posted on my status.

I am so excited! Today I have the cash to pay for my surgery in FULL!! Whoo-Hoo! This is so awesome! Hopefully all will go well and I will be able to schedule my surgery in December! Now I need to get as much information as possible before the big day. I am so happy. Just wanted let the "sleevers" know I am a soon to be sleever! I'm one step closer to a whole new life. Wow.

Hi, this is my very first post. I have been lurking on here for a little over a month now. I know there have been many threads created about Aetna weight history, but I can't find any answers to my question. Aetna requires you to have a documented BMI over 40 for the LAST two years. I have medical records of a BMI over 40 for 2010 and 2009. Does anyone know if Aetna considers the LAST two years to be 2010 and 2009?? Or do you think I need medical records for 2008 (becuase I don't have those). Any feedback will help. I have Aetna Aexcel Plus Choice POS2

OMG! I am on top of the world. I have been waiting what seems like forever. I first started considering surgery and researching my options back in February after my latest diet failure on Alli and reaching my highest weight ever. :sad0:I went to some seminars in April and May, but was still unsure which surgery I wanted. I finally went to the BSC in Dallas with Dr. Davidson (I had avoided his seminar because it was not free) and had a complete health screening along with a group information session and one-on-one session with the insurance coordinator, as well as a one-on-on consultation with the RN. Of course, I also met the surgeon. I loved the way they did things and c…