Insurance & Financing

hey everyone so i called my insurance today to ask what the criteria was for approval and they said they could not give me that information. they said my dr would have to submit the papers, thing is I dont wanna go through tons of blood tests etc just to find out im not eligible. If anyone knows the criteria for BCBS PPO please let me know thanks

Hi, my name is Mary and I've just registered with the site. Despite that, I'm very familiar with Vertical Sleeve Talk, because it has been my "go-to" place for help and advice these past several months. I began the journey toward weight loss surgery in April of this year and, thoroughly researching my options, knew from the start that I wanted the vertical sleeve. But my insurance is Anthem Blue Cross (in Southern California), and I felt pretty dismal about my chances of being approved. My surgeon, (Quilici) requested the sleeve, but, sure enough, Anthem denied the procedure on the basis that it is "always" experimental. They approved me instead for the gastric bypass.…

Hi--Just curious if anyone had surgery in NY with GHI (I beleive I have the GHI PPO) and get approved? I had called them back in Nov. and they stated that they would cover it; I called them again today, and they said they cover gastric bypass but not that the lap band is coming up as a non-coverable code. They told me to get my PCP to contact them for pre certification and that they might consider it on a case by case basis. I feel like I am getting the run around. I am planning on getting my surgery at NYU and just went to their info session on Jan. 22nd. Anyway, any advice is appreciated. Thanks everyone!! AMY :rolleyes2:

Wahoo!! After one denial(and appeal) Cigna did approve my surgery and I am slated for October 7th!! So excited.

My BMI is about 36. I am in the process of changing my insurance to GHI HMO and getting started with Dr. Kwon. Sleep Apnea, Pulminary disorder, asthma and weight too much for my joints. Can anyone relate and have you been approved?

Where exactly does it state Aetna wants a weight history?? I have my copy of Bariatric Surgery criteria and I don't see ANYTHING which asks for weight history. Can someone shed light on this? I'm only hearing about this requirement on the forums, not in my paperwork. thanks!

I am finishing up my 3 month multi discipline to get approval. I called the hospital where I am having my procedure to see how much I will need upfront. They told me it could be up to $3000 which is my max out of pocket with my plan. I will not know for sure until my surgery is scheduled. There is no way I can pay $3000 upfront for this. I am hoping it will be around $1500.

I am considering gastic bypass/Lap-Band surgery and I'm just starting to explore my options. I have BCBS of IL PPO insurance, and I'm looking for insurance to cover the surgery. I'm a 5'8" female, and I current weigh about 235. Over the past 5 years I've weighed between 252 and as low as 203. I did a low calorie, doctor supervised weight loss diet for 6 months to lose the 50 pounds (to get down to 203), but I gained most of it back within a year or so. Because of the calorie restircted diet, I had to have my gallbladder removed about 6 months ago. I have borderline high blood pressure (and I'm only 32) and high triglycerides. So... am I a candiate for surgery? Do …

I previously posted this following message on the Pre-Op forum on here, I decided to copy it and paste it on this new thread about Insurance & financing. If you find it interesting, you may want to show it to your surgeon. I tried to put it down in the terms that I understand them to be, but maybe whoever is appealing your case can put this in addition to all their other information, to try to get you approved for the sleeve. PLEASE READ THIS: Re: Unapproved for Sleeve - Ready to CRY -------------------------------------------------------------------------------- Quote: Originally Posted by jsm Thanks M…

Hello, I'm a new member to this website and just recently had a consultation for the sleeve. I curious if anyone has been in my situation before regarding insurance approval. I'm finding difficulities in finding records to show my BMI over 35 for 08. This particular "era" I had gone on a major diet & exercise program and lost 50+ lbs. Yay for me! Except, as soon as I jumped off the wagon I gained the 50 back + and extra 15. Wahoo! Anyway, so the only doc visit records for 08 describe my bmi under 35. The insurance lady at the doc office said to find records from 07 then with the BMI of 35 or 40 which I was able to locate one with 35 BMI & currenlty I'm at 42…

Hello all! I've been approved by BCBS Michigan for a bypass. My BMI was 40 when the paperwork was submitted, but is now 43. I am not comfortable with the bypass procedure and would like to get the sleeve. I have been denied the sleeve procedure and am filling a patient appeal. My surgeon will not write a letter on my behalf because I do not have particular co-morbidities. Do any insurance companies cover the sleeve as a stand alone procedure for my BMI? Does anyone know how close (or not) we are to insurance companies covering it? Have any of you been successful in this type of appeal to your insurance co? Thanks!

Hi My company is changing Insurance Sept. 1st and I currently have Aetna and I am in the process of getting tested and doing all the requirments for Aetna. I am going to my 2nd visit and Aetna requries 4 visits. Now my new insurance is Principal Life Insurance and I have never heard of them. Has anyone heard of them? What are there requirments? Thanks if anyone can ease my mind.:thumbup:

I have UHC/UMR and its changing the 31st of Dec... Does anyone know how long it can talk to get this approved and done?? My 1st surgon visit is wed the 15th and i have only attended the sem, adn teh support group... I don't knwo what else to do till the visit.. can anyone help???

*added* What do the weights need to indicate? What if two are considered over a 35 BMI and one is about a 33 BMI? Do all the weights need to be 'within' their value (35+) ?? I moved 3000 miles just over a year ago, so don't have records from just one doc on weight history. I have something from my OB in Dec 08, Endocrinologist in June 09, and current PCP in Feb '10. Do you think just the face page copy of my visit indicating my weight is good enough for them? Thanks for your help! :biggrin2: april

I apologize in advance for my long leadup to my question. I had an appointment with my PCP today concerning switching meds for my RLS and told him of my plans to pursue WLS with the LAP-BAND - he was very supportive. I am attending a seminar tomorrow evening. My BMI has been over 35 for most of the past 20 years and I have tried repeatedly to lose weight only to gain it back plus more. My BMI is currently over 40, I have been on medication for HBP for at least 13 years, I have obstructive sleep apnea and have used a CPAP since January of 2006 and am having a test done to see whether the air pressure needs to be increased due to my weight gain and daytime sleepiness. …

Paperwork is turned into the insuance company, finally! Started this process 3 years ago, got through consults and psych eval, and everything. Then had a wonderful little suprise roadblock we named Tyler and had to wait to start the process over. Had to start over with new insuance conpany learn all the new requirements which included a 6 month diet documentation required by my employer. Took my doc almost 2 weeks to get that to the insurance lady at my surgeons. I think everything is in order this time and hopefully I am just waiting for approval. But this whole waiting this is driving me nuts! I just really want to be approved. When should I start calling them to find o…

Hey everyone, I get my stuff submitted tomorrow and i'm worried that I might not get approved. I'm 234 5''5, I have one kidney,ashtma, borderline prehypertensive and borderline pre diabetic, have severe joint pains and have a family history of morbid obesity. Do you think i'll be approved?

My doctor referred me to a surgeon. When I signed up for the seminar with the surgeons office they said because of my insurance, Blue Shield HMO Sante, I would have to do a 6-month weight management program before they would see me and I can still go to the seminar because its good for a year. But then I got a letter from Sante stating my medical file had been reviewed and it was approved form me to see the surgeon. I've called Sante and they said I can make the appt. I called Blue Shield they said I have to do the 6-month weight management program. i called my GP's office and asked them to make the appt, but I don't want to go and find out that is was just for them to te…

I have been looking into the lap-band for 6 months now. We were going to have to pay out of pocket for it because our insurance wouldn't cover it so I had pretty much given up. My husband just recently joined the Army. We will not be registered for TriCare benefits until January, but I had some questions. I've read on the TriCare website that it does in fact cover lap-band. Also that I qualify due to my height (5'0''), weight (215) and BMI (42). My question was about the financial end. Do they cover all of it? Or are you expected to pay some? It is definately something I am interested in and would like to financially prepare for it if I can. Thank you for all your help!! …

For those of you that have been approved by your insurance company...would you mind sharing your BMI and insurance company and any co-morbidities. This will be comforting to those of us who0 are awaiting hearing from our insurance.. Thanks, Jill:smile2:

Hi All, Lately one of the lapband commercials that plays frequently her in S. Ca implies that after Obamcare comes into full effect that WLS will no longer be covered is this true???? I know Kaiser has been ramping up on their surgeries to the point of months of back log is this because of that? I have a friend who went through the options program she has a year to make up her mind but if it is on its way out..... Nancy

I am in the process of doing the three-month intensive diet/exercise/behavior modification requirement for Aetna. Does anyone know if this means that I have to see the psychologist and nutritionist a total of 4 times or 3? I know that this seems like a silly question, but the psychologist says it is only 3 and the nutritionist says it is 4 (1st visit, 2nd visit after one month, 3rd visit after 2 months and 4th visit after 3 months). And, does it matter if you go over or less than 30 days in-between visits?

Before starting out on the 6mo journey just to find out you're NOT approved, is there anything that happens early on to indicate that you will/will not be approved if you complete all the required hoop-jumping? If i end up being denied after all the appts and such, i'd have to go the route of self-pay... maybe i should skip the process and self-pay now and be on my timeline. kwim? I've been in the queue w/my Dr all morning so i haven't been able to get this question answered... Thanks for any input! :001_cool: april

Okay so the BCBS that I have does not cover any bariatric anything. I had my band done under insurance through my last job. I lost my job, went on my husbands ins, he switched jobs and now we have BCBS again. You would think that they would still cover bariatric conditions if you were covered before. I wrote an appeal letter. They said that they would cover pre existing conditions. I called them and they said that because of the place my husband works for has an exclusion for bariatric treatment at all, that is not concidered a pre-existing condition. What do I do now??????? I am so lost and I don't know where to go from here. My Dr wants this thing out because …

Hello, I would like to have weight loss surgery, maybe lap band, but not sure exactly. I have completed a six month of supervised weight loss treatment with my family doctor per Medicaid insurance request in 2009. I was a BMI of 39 ½. I have asthma, insomnia, Gastro reflex disease, and chronic cough, usually occurs after meals. I have sent six month records to Winston Salem, I have not received a direct answer from them for two month. I contacted them one last time to check on the status, the nurse told me I was rejected, I wondered why and spoke with director. And found out my records were not read. Now in 2010, Even though my weight loss and weight gain is ins…

Great news?. I check BCBSIL procedure web site every few days to see if it has been updated for the sleeve ? and it has been updated today. I could not find the words "investigational" with "sleeve" - If I'm reading it correctly - VSG is now accepted.... I was a few weeks too early - I was denied and approved after I did the appeal...

I am very ashamed to even admit this, but I haven't been to a doctor in the last couple of years before getting involved in the pre-surgery programs. Unfortunately, I don't have the history Aetna requires. My BMI currently is just over 50. Now any reasonable person would know this didn't happen in the last week and a half.....but we are dealing with insurance, so reasonable may be unrealistic. I'm working on some alternatives. I can get a medical record from 2005 and I will send that. I also am putting together a series of pictures where I can hopefully print the time stamp with it. I'm thinking about asking one of the trainers from the gym who has become a close person…

I want everyone to chip in if I am right or not. I had a lap band for three years. Pulled the port loose at work, it erroded and infected my internal band leading to removal of my band several weeks ago. My doc says after one failed band he will not do another. He said I could do a sleeve as a revision. Worker's comp has been headache from beginning. They refused to pay in the beginning and caused me to lose my band because of an open hole in abd for weeks on end. I have been in surgery three time to correct the problems including removing my band, they paid for all this. They are now refusing to cover the cost of the sleeve. I feel like they are responsible because their…

Hello, This is my first post. I have been a lurker for about 9 months now. I have been inspired in my Quest for the VGS by so many of you and your courage. I too have done all the research and feel that the VGS is my best chance for long-term success with the battle of the bulge, and the most safe & effective way for me to get there. I have co-morbidies, along with my current BMI of 38.4, I am eligible for the surgery. I have Bariatric Insurance coverage for Bypass & Band, but I found out today from my surgeons office, no VGS coverage, "to date". Not FDA approved, blah, blah!! I work for a hospital that is a "Bariatric Center of Excellence" and promotes the …

I know what the Aetna plan says here, but I am just not sure what it means exactly. My BMI definitely qualifies me, what has me scratching my head is the part about a six month Dr. supervised diet/exercise plan or a 3 month multidisciplanary program....what?? So, if you have Aetna, what did you do? How long did it take to get approval? Thanks!

For those that have Aetna HMO how long did it take for them to approve your sleeve.?? Connie :001_tt2:

Hi all! I was denied by Aetna due to "lack of weight history". I submitted my weight from 07, 08 and this year; not much has change. I went to my gym and had them type up a letter stating my weight from 09. I hope that works! My question is: how long does it take to hear back from your appeal? I'm super nervous! Thanks for your help in advance. :lol0:

I have a new job which means new isnurance. And to the best of my knowledge my surgeon isn't covered :biggrin: And I have to go in for an unfill which means it's all going to be out of pocket. I'm going to have to find a new Dr unless I want to do the rest self-pay.

I've just started getting all of my testing out the way in preparation of the surgeon sending my records to the insurance company for approval. I'm wondering if anyone else has used BCBS NYS Teamsters and how the approval process went. I have a BMI of 37.5 but I have mild sleep apnea, mild heart condition with a letter from the cardiologist stating that weightloss would benefit my heart condition and I also have high cholesterol. Anyone else with similar conditions and how fast was the approval or denial (hopefully the first one). Thanks in advance for your response.

My insurance will not budge on paying for my lapband. Anyone have any advice to try to get insurance to pay.

I was denied by BCBS of CA on August 3rd:mad:, due to the experimental nature:confused1: of the VSG. I finally wrote an appeal letter. It doesn't have all the references like some I have researched, but I hope it works:001_unsure:. If you want to read it, I would love some opinions. Its posted on my blog From Thick to Thin: Insurance Appeal Letter Wish me luck. It has been a long 3 months since I first went to the doctor back in June.

I have yet to set up a consultation with a doctor, but have the paper work to start filling out before I can agree on an appointment. How likely of a candidate would I be for coverage from my insurance? I know all insurances are different, and they all have their set of rules. I just don't know if I would even be considered. Like most of you all, I've always struggled with weight. I've been able to lose weight, then gain it back and so forth and so on. This time around it's much worse as I had my spine fused a year ago, and have gained 70lbs and am in a lot of pain. I know it's largely because of the weight gain. With me being in pain it's very hard to eat healthy an…

Hi I was wondering if anyone out there has submitted their 5 year weight history to UHC or any other Ins company and it was not a consistent 5 years? That's the problem im having now I have 5 years of weight history but not consistently ya know. For example I don't have weights for 05&06. Why? No insurance couldn't afford to go to doctor but however I do have 2000-04 weights (courtesy of past OB/GYN) and 07 weights till present with PCP and current OB/GYN. Any advise would be good. Thanks so much!

Hi everyone, I live in the Tricare north region and am interested in LAP-BAND® surgery but do not weigh 100 pounds over my ideal weight. Has anyone with less than 100 pounds to lose been successful at getting approved by Tricare prime (or standard if it is easier to get approved) for surgery? How difficult was the process? Did you have to submit an appeal? What do you feel helped you get approved without meeting their requirements? I would really appreciate getting some input from people who have gone through this experience before me :confused:

I'm hoping to get the okay for Lap-Band®, but my insurance policy (Blue Cross Blue Shield of MS) says this under "Limitations and Exclusions": "Exogenous obesity, including any prescription drugs, surgery or other treatment." Has anyone else encountered this in their policy? I know "exogenous" means obesity caused by overeating, but really hoping that means they will still cover it if it is deemed medically necessary. Any advice?

Greetings all- I submitted my first level appeal with Premera BCBS recently. My appeal adventure resulted in a change of surgeons for me. My initial surgeon, who I was referred to and is well-known in our locale for skills, according to the office staff, would not participate in my appeal. This included an unwillingness to read my letter to simply ensure I was not overstating conclusions found in medical journal articles. I found this attitude unsettling...was I just $$$ in the door--what about after my surgery?? Long story short, with a little research, I located another surgeon closer to my home--and just as highly skilled. Without revealing my story to his office s…

Hi Everyone!! okay soooo. I wana get the LapBand. I have United Health Care. I have a few questions. I hope yall can help me. 1. If my BMI is over 40 will I automaticly get approved? 2. Has anyone used Dr. Steven Fass out of Austin TX and does he make you jump through all kinds of hoops? 3. Since my BMI is 41, I have hypo-thyroid and hyper-tension, depression and back pain do u think I will automaticly get approved with out needing to prove 5 years of weight history and do the 6 month pre-op diet? I was born over weight. It runs in the family. I have never ever been thin. I am almost 285 lbs today. I have never been able to keep up on my health due to a rocky life st…

I'm holding my breath for a revision to Wellmark's policy sometime soon....I am in IA and I hear about surrounding states getting approval for the sleeve through BCBS. Anyone have any inside info? Thanks.....

Did your insurance pay for band removal??

Hi all, I am in the insurance authorization stage. I'm 5'5" and I weigh 184 pounds. My goal weight is 120 (I'm a small framed woman). I have high blood pressure and high cholesterol. The dr. put me on meds for both, but the side effects are horrible and I don't want to take meds. My Dad had a stroke from high blood pressure at 55 and he passed away from heart attack at 61. My 68 year old Mom has been diagnosed with congestive heart failure. I feel like a walking time bomb. I've been overweight for the last 20 years (I'm 47) and I've tried every diet out there. I've lost weight and then regained it and I'm done with the rollercoaster. I want to get banded so that I r…

I am in a desperate situation as I am trying to get the other half of my funding in a few days to secure a date to get this thing (lapband) out and a sleeve done. I came across a website called PatientSource.net and it all looks legit but for the weirdest reason it won't let me apply. I was wondering if it ws legit at that point. Anyone else use them and get approved? Is there a catch?

I have the option to split my surgery over two credit cards or use My Medical Loan for their "no patient left behind" program - anyone have suggestions or advice? I was filling out the paperwork for MML and decided to google for some info on the program and found some negative reviews about them being bankrupt, etc..... and input would be appreciated!

I'm new here and concerned about insurance, too. I'm still debating even having a lapband, but it is good to know there are a lot of people out there going thru what I am. Thanks everyone. p

I've been morbidly obese for several years. I've too many years on this crap and I'm really just done with being overweight. I've tried the average methods-dieting, exercise, dieting programs, gimmicks...nothing helped me lose enough weight after a certain point or keep it off. So I started looking into surgery. I was working at AT&T at the time who had Blue Cross Blue Shield then switched to United Health Care. When I called United Health Care, I was told neither Lap Band or Gastric Bypass was covered. Now that I just started at United Health Care at a call center, I was anxious to find out if the employee insurance covered bariatric surgery. When I called I…

I am going to have surgery in Jan. or Feb. 2011. I just started my Diet July 7,2010. I want the VSG, however My Doctor informed me Medicare does not pay for VSG. I do not want Gastric Bypass because I am afraid of the malabsorption problem and the dumping sym. I also do not like the intenstine being cut & moved up to the stomach pouch. Does anyone know if Medicare will be approving VSG in 2011?:thumbup: