Insurance & Financing

I have Humana through my employer. I have been doing alot of the researching "online" because I am really concerned about starting down this path & then not getting approved. My insurance pays for the surgery with a $200 copay. I found out that they do have a requirement of 6 mos doctor supervised - which I have done more than once thru a doctor with phenteramine. I am not sure if they have "specific" requirements on how the doctor is to submit the information but it has been almost a year ago that I went through that - is that too long? Anyone who has had experience with Humana that can give me feedback - I appreciate it!

Hello, I went to my pre-testing today with my doc, only to find out that after speaking with my insurance Empire BC/BS of NY, they will not pay for the sleeve, that it was considered investigational. My Doc asked how could it get approved he was told that it had to be medically necessary to the point I coul not get any of the other surgeries. My hubby is totally against the bypass, and I promised my kids that I will not get the bypass.I feel like a liar. I feel like now, I am stuck with the Bypass. I feel so lost and depressed. My heart was so on the sleeve, I dreamed last night, that I had gotten it already. My Doc said he asked around to other Docs to see what the…

My insurnace is requiring a three month supervised exercise program with an exercise therapist. Does anyone know EXACTLY what the insurnace is wanting. And I mean, I know it states three months but what would they be happy with? A couple days in Oct, a couple days in Nov, and a couple days in Dec. Anyone been through this before?

Can someone tell me if medicaid covers lapband surgery, and is it the same requirments as regular insurance?

Hi you guys I have been searching and searching but I can't find much information about weight loss surgery in Hawaii. I was looking into the lap band but after much research decided to go with vsg. Okay so my question is does anyone have ANY information about vsg being done in Hawaii? or at a MTF such as triple?

Hi all I have BCBS Louisiana (office of group benifets) and it is not covered on the Plan. I have contacted the doctor that I want to do my surgary and filled out all the paper work, but since my insurance will not cover the surgary i would have to appeal. I hear they do not approve any appeals eaither. I have not applied for an appeal yet, I was told to try and get a loan but my credit score is not high enough for the loan : ( I am in the process of rebuilding my credit, was wondering if there were and Government grants available the medical loans? I am 34 and in general good health but weigh 301 and i am 5'5 my family history is bad lost both of my parents at an early…

I need some advice, I have Blue Cross Blue shield of michigan and went to a consultation for the lapband, the lady verifying the coverage did not think that I would have a problem getting the surgery but once she called they told her there was an exclusion against bariatric surgery from husbands employer. I am looking through my policy as this is new insurance to me and I see nothing under exclusions for bariatric surgery however there is a clause under exclusions that says therapy or hospital admission for weight control, but that doesnt not seem like it would apply to my lapband procedure, and I was planning to have it done as an out patient procedure. What can I do if …

I had United Health Care when I got my band. I've changed jobs since then, and I now have Aetna. I'm looking at going back for my first fill/follow-up since getting this insurance. How likely is it that Aetna will cover lap-band-related things? I'm terrified that I'll go for an appointment and then find out none of it is covered. I want to take care of myself, but money is tight, and I just don't have a lot for out of pocket expenses.

wondering if anyone with bcbs wellmark of Iowa has been approved in any case or with any appeal?

Here's a little background first. I've been thru the seminar and 1st appt with my surgeon. I have my Psych eval, Nutrition eval & PCP appt within the next two weeks. And I have BCBS of GA. Ok, I need some help. It looks like I meet all of the criteria to have insurance cover my surgery but what does this mean?... "The patient must have actively participated in non-surgical methods of weight reduction; these efforts must be fully appraised by the physician requesting authorization for surgery" To me that means my surgeon, not my PCP, but when I went to my 1st appt the lady who handles ins said that probably means I need to have a history of physician supervised w…

Hi! I'm new to the site and was wondering if anyone has dealt with United Healthcare (Caterpillar)? I've been to see the surgeon and after talking with the adminstration was told that in order for United Healthcare to pay, I would have to have five years of documentation along with a BMI of 40. So, I'm guessing, I'm already going to be denied, since my BMI has never been 40. Has anyone ever been denied because their BMI was 39 and not 40? Thank you!:confused2:

I am so happy and surprised right now! I just got a call from the surgeon's office to tell me I'm approved. I did not have the the doctor weight history and I didn't think they'd give me the green light. I put together a fairly compelling packet of information and letters for the insurance company and I also sent a copy to the claims advocacy department within my husbands company (I'm insured through him) I would be happy to share what I did to help anyone else get approved.

Soooo...as some of you may know, my papework was submitted last week for VSG. The insurance coordinator at my WLS practice told me that it would be about a week before I heard anything back. Well i called today and was told that I had been denied based on the surgery still being considered investigational (big surprise). Then I was told that my surgeon had already scheduled a peer-to-peer for Friday (tomorrow). Is this a good thing, or a bad thing? Is this usually how it goes? Somebody help me out here...I'm confused...

So, I have completed my insurance required 6 months of weight monitoring and nutritional counseling, done all of my pre-op testing, both that the insurance requires and my surgeon requires. All of my paperwork was submitted on Oct. 5th.....and today I find out that my bariatric nurse (THE one person who decides if it is approved or not) is going on vacation all next week. So please God, grant me patience, because heaven knows I need it. My surgeon's office won't give me a "date" until I'm approved (can't say I blame them) but it is literally driving me nuts that I CANNOT place a surgery date on my calendar and PLAN MY LIFE AROUND IT. AAAARGH! Oh, and I guess the i…

Does anyone know where to get lap band done in Maryland that takes tricare? Is Bethesda the only facility thats like 3.5 hours away!

I am curious if anyone has received approval from Personal Care hmo. Just wondering if anyone knows how hard it is to get approval. Anyone with experience with Personal Care please let me know. thanks

Hello Everyone - I am new here but have been reading posts on this board for months now. I just got denied from United Health Care EPO Choice Plus today. I am extremely upset and am looking for some appeal success stories. I was not approved due to the fact that my BMI is 38.2 and I did not have evidence of any co-morbidities. My policy covers those individuals with a BMI of 35+ if there are one or more co-morbidities present. I am planning an appealing as I do have a family history of heart disease and diabetes, and I also have knee, back, hip and foot pain. I have not seen an orthopedist for the joint health issues but plan to do so if the medical diagnosis wo…

I just moved from WA to CA. I live 1 hour from Modesto and 2 from Sacremento. Most facility's are not accepting patients from other doctors. And when they are I am quote $1800 for an intial visit and fill. I don't currently have insurance until the begining of the year. Does anyone do where I can get fills for a reasonable cost?? Or is there an insurance company that I can pay for to help with the cost of seeing a new doctor?

Hi all I was wondering what insurance companies in Louisiana cover the VSG I currently have BCBS through the office of group benifets and they do not cover the surgery. when open enrollment comes next year I was thinking of changing policies, but I do not know who actually covers the surgery. if anyone out there is from Louisiana and currently works for the state and knows please let me know! thanks

Some potentially big news came out a couple of days ago. Lap Band now has its own CPT code from the AMA! As many of you know, the way a physician files for a service performed is by providing a CPT code to the insurance company. When a new service is 'invented' there is generally a several year lag period until a CPT code is assigned. Until that point the physician needs to use an 'unlisted procedure' code which has been the case until now for Lap Band. This creates problems for both the patient and the physician, since the insurance company can essentially say 'this procedure doesn't officially exist' and will assign any value to it that they wish, or just deny it. …

Hello, anyone have aetna who has been approved ? I am currently finishing my 3 month dietician diet and was given an approval from the pychologist. I am really nervous because i think aetna sucks, anything i should do or expect when i finally submit the paper work?:frown:

I have MVP insurance and was just wondering if anyone knew what hoops, if any, I would be required to jump through before being approved. I have a BMI greater than 40 with a co-morbidity of high blood pressure.

Hi Everyone, I am new here and this is my first post. I had my first visit to explain the lapband and all the dr.s visits. I have my psych, nutritionist, pulm., and cardiologist all on the same day which is great. I have been reading here that Aetna requires 90 days of monitored exercise and dieting. Can this be done with your PCP? I just don't want to be denied and am trying to do everything I can beforehand to prevent it. I hope this goes smoothly. I can't wait to get banded! :smile:

I have bc/bs and Aetna POS and neither one of my insurance cover's the lapband I called both insurance companies and gave them the code which is 43770 and they told me that they do not cover the lapbad, has anyone experienced this? What should I do still submitt it to the insurance company and go from there?

Anyone have any experience or advice for dealing with Oxford?

Hello all!! I called Kaiser today to scheudule my appointment to see my PCP so that I may get a referral for a lap band. My appioniment is on Sept 10th (wish me luck):cool2:. The only thing that worries me, is that when I called customer support (Kaiser) to see if Lap band was coverd, I was told it wasn't only the gastric bypass (which I DO NOT want):thumbup:. But that I should keep my appointment with my PCP and if she felt it was medically necessary, she would know what to do. Has anyone in Southern California (Kaiser) gone through this? My BMI is 46 or 48. I would think that I would qualify just on that. I don't have any health issues though. Will this NOT help my chan…

It is open enrollment time where I work and we have 2 choices....Kaiser or BCBS (national acct ppo), I know location matters, I am in Virginia After years of research I've decided the sleeve is the procedure to go with, I would love to hear if anyone has had the sleeve approved through these companies, what the requirements are, and what "hoops" they had to jump through to do so.

In January, I called my insurance company and asked if WLS was covered. I was told yes as long as I met the criteria - co-morbidities, psych eval, meetings with nutritionist, 5 years or more over 100lbs overweight, bmi, etc. I did what I was supposed to do and received the approval from the insurance company and 3 weeks later had my surgery. Last week, I received a statement from BCBSNC showing claims submitted and subsequently DENIED for costs of over $100K. They denied the surgeon's claims and they denied the hospital's claims. A few days later, I received another of the same denial letters this time stating they paid $5K of the surgeon's fees and $58K of the hospital's…

Well, After EVERYTHING I went through, all the procedures, all the stress, it turns out BCBS misquoted my Provider and the treatment of obesity is an exclusion. BCBS told my provider that yes wls was covered, yes the sleeve was covered, and here are the things that need to be done before pre auth (endoscopy, dietitian appointments, upper GI, psyc eval...yada yada yada). :scared0: I was about a month away from surgery when I was looking through our plan docs for chiropractic information. All of a sudden I was bit in the face with an obesity exclusion! What!!! OMG, I called my provider. She called BCBS and sure enough, excluded. BCBS said don't worry, if it s a misquot…

My daughter has been very overweight much of her entire life. She has seen the same PCP for the past 3 or so years pretty regularly so should have a record of her weight... BUT, his scales only go to 300 pounds so they have been unable to weigh her. What happens in a case like this? She only went to the GYN/OB once during that time so, essentially, she doesn't have any weight records (I'm not even sure if their scales went any higher). Can the doctor state that her BMI had to be over 40+ due to the fact that their scale didn't go high enough? Will that be enough to fulfill the weight record requirement? Thanks!

Hi, Just wondering if anyone has any experience with BCBS of Georgia insurance? I've been to the seminar and my first DR appt is on the 13th.. I'm SO nervous. I've called my ins and they do cover WLS but still consider the sleeve as experimental. I thought I wanted the band until I researched more and found that the sleeve is perfect for me! ANY info about BCBS GA will be helpful. Thanks! Tom Petty says it best... THE WAITING IS THE HARDEST PART!!

:mad: So I have already completed everything that I need to to have my Lap Band done. I assumed that I was awaiting approval by my insurance company as was my Surgeon's office. My paperwork has been submitted for 2 weeks now. I called my Insurance company which is BC/BS of Michigan, and asked for an update. They informed me that 'BCBSM does not pre-authorize bariatric surgery procedured." "As with any other covered medical service, we expect the physician to document in the clinical record indications for and medical appropriateness of the procedure." and then it went on to list the requirements. I meet each expectation. I called my Surgeon's office with the report. They…

Hello All, I have just started the process this month. I went to the seminar on 9/1, went to see my PCP on 9/21 (will see again tom. 9/28 for tests). My question is I want to have the surgery before the end of the year, so what steps do I need to take to complete the 3 months versus the 6 month authorization period? I called to talk to them (Aetna) but I was transferred 3 times. I need 3 visits with nutritionist/psych eval/ and what besides that...Do I have 3 visits with surgeon and/or 3 with PCP? Any help will be appreciated...:smile: Ralpheal

Hey guys! Quick question! This is my first time every paying for anything medical out of pocket (since I do have insurance) however, I paid cash for my VSG and I was told that we could get some of the money back at the end of the year? Does anyone know any specific information regarding this? Thanks.....

I'm a 38 year old male living in Sacramento...I've been overweight for about 15+ years now...although I don't look it..I'm actually about 70-80 lbs overweight with a BMI of about 35-36. I've really thought hard about getting the lap band procedure and have recently just got off the couch long enough to start putting this desire into action. My insurance is Blue Shield of California and I've been told it's a coverable procedure BUT if my BMI is between 35-40 then I would need a co-morbidity to get pre-approved. Yet, I don't think I really have a co-morbidity that applies..I've got a good heart, no diabetes, no disorders, take no medications, have a good blood pressure...…

I am trying to get info for my mom who needs a band to sleeve revision. Has anybody gotten Insuance to pay. Im especially interested if you have Health PLus as that is what she has but would love any info anybody has??

Just wondering if anyone has used BC/BS of MI..and what your experience was. Prior to my surgical consult my Insurance company was so helpful answering any question that I had. Now since my paperwork has been sent, it is as if you have nobody to talk to. I was told prior to that I could call and do a status update...now they are tight-lipped and I was told last week that it could take 45 business days before I received a pre-determination letter and I was quoted November 19 as the date that they had to send me and my Dr's office the letter in mail. They would not allow my surgeon's office to fax anything to them...only snail mail...I am so sorry to be venting like this...…

Anyone had any experience trying to get coverage for the Sleeve surgery from this insurance Provider? I have Hills Physicians specifically. I have placed a question in the "contact us" email inbox for my provider and will need to wait a few days for response. If I don't get one by Wednesday I will call. Thank you!

I received a call yesterday from the company my insurance company uses for pre certification and the woman told me my lap band procedure was certified. Does that mean I am approved for surgery.

The letter came on Friday, Sept. 17th. It stated I had 10 days from the "date of the letter" to ask for a peer review. The letter was dated Sept. 9th. Today is the 10th day and it's a Sunday....SCREWED on that option. I will contact the surgeon's office tomorrow about filing an appeal. Then (if I'm reading the letter correctly) when the appeal is denied, we can ask for a peer review. Their reason for the denial (of course) was the ole experimental/investigational excuse. My hospital was the first in the USA to perform the Biliopancreatic Diversion with Duodenal Switch. It is a malabsorbtive procedure in which a portion of the stomach actually is removed. In addition to…

Hi Everyone, Sorry if there are other posts about this. I've tried using the search feature but haven't found any similar threads. Like many others, I was originally set on lap-band surgery. I went to my consultation, the surgeon said I was a good candidate and it looks as though my insurance will be approving the procedure (I have Federal BCBS). I starting reading more and more stories about complications after lap-band surgery, I really thought hard about all the doctors visits for fills and unfills, and not to mention all the extra expense of it all (time away from work, $ for the appointments, $ for gas, etc.). After researching and talking to more people abo…

And I have been a single Mom without emotional, physical and financial support for 20 of my sons 21 years of life so with trying to put him through college, there's no way possible I can afford the Lapband surgery and my credit sucks! I was one of 600 applicants to win the surgery through a local radio station then I was one of 100 then one of 5...but didn't win...I was so close and thought of how I was going to live my life with the Lapband only to be heartborken once again. I say again because my Ex and I were going to get married next month and his insurance covers the surgery 100%, I was going to get it after we got married, went through the 3 hour seminar and have be…

I got approved through BCBS of North Dakota on first appeal! They sent it out to an external reviewer, and they said yes!!:scared0: I am soooo stoked! So, everyone who is denied the first time... fight back! It is possible.

I recieved my approval for VSG today! Got a letter in the mail. I have Federal BCBS Basic administered by Wellmark of Iowa. I know the Dr. that is doing my surgery had never before submitted for federal bcbs coverage and they were unsure as to whether or not it would be approved - in fact they even had an appeal plan in place in case it was not! Something interesting to note on the approval form: "Prior approval is not required for this procedure for FEP however; a medical necessity review has been completed. Medically approved 43775" So federal employees in Iowa - Wellmark is approving VSG based on medical necessity. I'm guessing it's only a matter of time befo…

Yes, it's true!!!! After months of bad news, finally got the good news, I WILL BE GETTING MY SLEEVE! I must thank with all my heart, sleevejeani (formerly jeaniwantsasleeve) for her help with the appeals and IMR review board process. I could not have done it without her. Also thanks to tiffykins for her help. This board is awesome!! Next step is a follow up visit with my surgeon on Tuesday (they haven't seen me since April) and then hopefully I will get a surgery date-most likely in September. I am excited, scared, hopeful, nervous, happy, worried, so many emotions going on. I feel like I've just won a big prize! I still can't believe it!

This is an update to my post of 8/21/10 in this forum. Today, I received a letter from Premera BCBS overturning thier denial of the sleeve. Thier decision to overturn the intial denial is based on medical necessity because I have Celiac Sprue. If anyone wants a copy of my letter, I'll be happy to email it to you. My new surgeon wrote a great letter, and I meet with him this Thursday. I must admit I'm a little overwhelmed with the news! Never give up! To our good health- Fit:thumbup1:

Tomorrow I go to the doctors office which will complete my pre op requirements and the insurance coordinator will send off my package to Aetna. I've written before in other threads that I am missing the doctor weight records for 2008 and 2009. I have prepared a package to try and compensate for the missing info. The package includes photos with time date stamps from that period of time, photos showing weight issues throughout my life, weigh ins from the gym with a letter from my trainer, a very detailed outline of my diet history over 30 years, and a letter that I hope is compelling enough. If this does work, I will be happy to share my letters and anything I have le…

Does anyone have this insurance? Did they approve you for lap band? Do they even cover lap band? I was just recently employed and will be getting Core Benefits Ins soon. I am curious if anyone else out there has this Insurance that was a approved for this surgery. I wont have insurance until November 1st, I am dieing to know if they cover it! :thumbup:

has anyone had medicare to pay for the surgery

Hi all, For the past 2(ish) months I have been trying to get this entire process on a roll. But, I have encountered some obstacles. My BMI is (and has been for years) around 38. Most insurance companies require a BMI of 40+ or 35-39 with comorbidities. Currently, I dont have any comorbidities. Are there any options for me? I know I could gain the 15ish pounds to be over 40 BMI but, for my 5'1'' height 15 pounds is alot. Also, I believe my insurance (Aetna) requires 2 years of over a 40 BMI).I have been to one PCP and have expressed to her that I have sleep apnea (which I really don't) and rattled off to her some of my "symptoms". I'm trying to get just a clinica…