Insurance & Financing

My insurance company states: Approved surgical procedures may include gastric bypass, gastric stapling, gastroplasty, and the Lap-Band? adjustable gastric banding system. Any ideas if VSG fits into any of these categories?

I was told by my doctor's office that I won't qualify for insurance coverage because I was below 35 BMI for a year. That year I was on a supervised drug/diet and did lose weight but never got below 33 BMI. I read on Gary Viscio's website that he has an early intervention plan that I would like to participate in. I figure if I get an attorney involved now it will save me a lot of heartache in the long run (fingers crossed!) I have emailed Viscio Law and called. It has been over a week and I have not gotten a response to my email. When I call, I get the message that the box is full. Any suggestions? Am I wasting my time?

Hi all. I'm new posting to this forum, but I've been reading for a few months now. I'm 2 months into the required 6 month diet period now. The question I have is AIGB in Richardson is not considered "In Network" by Cigna. I'm being told that AIGB will honor the "negotioated" rates with Cigna but they will not know what that rate will be until after the surgery. I'm told the most I will have to pay is the balance of the "In Network" out of pocket costs. Now I know it's better than having to pay for the whole thing myself, but can someone shed some light as to what they actually had to pay, or what their negotiated rate ended up being? Thanks in advance. Oscar

I am trying to decipher this portion of Cigna's policy. The first paragraph mentions the 6 month diet within last 2 years. The second paragraph mentions 6 month participation in weight management program within the last 5 years. Are they giving us 2 ways to meet the diet qualification? Thanks for your time. Cathy Failure of medical management including evidence of active participation within the last two years in a weight-management program that is supervised either by a physician or a registered dietician for a minimum of six months without significant gaps. The weight-management program must include monthly documentation of ALL of the following components: …

My Message on the first one was suppose to say Medicare.. I need to find an insurance that will pay the other 20% of my medicare because my doctor has to have it up front before the surgery. If anyone knows a secondary insurance I can look into please let me know.. Thank you ......

I have seen this question asked but not answered so I am hoping by posting fresh I can get answers from those on Aetna that were "on the line" of the 40 BMI. I applied with Aetna and jumped through all the hoops last year only to be denied because my BMI didn't actually hit 40 until just before I started the process. I have none of their listed comorbidities--I have joint and mobility issues do to the weight and that isn't covered. So I will be reapplying when I have 2 years of records with 40 BMI. But is it really only 2 years of proof, or is it technically 24 months? In other words I was weighed at 40 BMI in July of 2009. I am still at 40 BMI (and will make sure…

Hi everybody, I'm new on here and I have some questions. I have BCBS of Texas. My surgeons office has submitted all requirements and paperwork to the insurance company. Has anyone on here dealt with BCBS of Texas and if so, how long did it take to get your approval/denial? I am getting so anxious...LOL:rolleyes2:

Hey there. My name is Megen and I have insurance through Cigna. I am in month 2 in the 6 month program, and I was just wondering what everyone submitted for insurance approval. I have read the criteria for the lapband several times, and called the 1-800 number a few times also, but I was wondering if I could hear some firsthand experiences with getting approved. I am tracking everything I eat for the 6 month program (although I haven’t lost any weight- actually gained 8lbs), I am tracking every time I work out, and I am making all the necessary appointments for the letters of medical necessary. Also, I am aware that CIGNA covers 90% of the cost for the lap band, but …

Hi Everyone ~ I got a call from my surgeon's office and they scheduled me for my first meeting with the surgeon on April 2. I can't believe I have to wait so long but I'm just proud of myself that I've come this far. Ok, the billing clerk didnt sound too optimistic about me getting the VSG approved. She said that they have only done 4 or 5 VSGs and only 1 person got approved on the first try and the rest were appeals. I called my insurance company and gave them the code that I saw on this website (43755). He said that the code is in their system but he gave me the run around on whether they would approve it or not. He couldnt tell me if its still considered …

I have completed all my pre-op testing and found out this week that I was denied because UHC is requiring that I submit documentation of a six-month supervised diet. When I called prior to beginning this process UHC told me the only requirement is a five year weight history and eligible BMI. I submitted more than five years history and my current BMI is 50. I am soooo very discouraged. I have yoyo dieted all my life and I'm truly ready to make the commitment. But I feel the lapband is they key to loosing and maintaining weight loss. Has anyone else been required by UHC to do the six-month diet? Any suggestions? I feel like this is just a way for UHC to prolong my agony!! …

Just wondering if anyone has had luck with Pacificare's PPO in CA? It looks like Bariatric procedures are excluded in the handbook but I’m not sure if this is a case of no means no or no unless you have a medical need. Thoughts?

Hi! I am new to all this, but hoping for a little advice. My insurance only will cover 50% of weight loss surgery. I have UHC Choice Plus. Because I would have to pay so much out of pocket, I was leaning towards the lap band. The more I read up on the different surgeries though, I really feel that the Sleeve is the surgery for me. I am seeking approval through my insurance, but when I called with the code (listed on this site), my insurance told me this code doesn't exist. Does that just mean "my" insurance doesn't cover this code? Am I doing something wrong? I can't afford the full surgery out of pocket... and not 100% sold on traveling to Mexico. Any advice? Th…

Does anyone have Southern Health Insurance? Soon to send in for approval and dont know nor can I find anyone that has gone through Southern Health Insurance. Any input would be greatly appreciated......Thank you Lisa:thumbup:

Howdy y'all This question is for those of you in California that might know about DMHC (Department of Managed Health Care) and IMR (Independent Medical Review). I've heard from many sources that in California you can get the DMHC to overrule the insurances' requirement for the 6 month diet by getting an IMR. I have yet to get my psych evaluation done. I thought I would have more time (if I had done the 6 month diet). Can I file (and get approved) by a IMR with a contingent that I pass my psych eval? Also, does anyone have a sample IMR letter that I can cheat off off? :smile2:

Hey All, My insurance Co., Aetna Health Care has approved the cost of removing my band but NOT the sleeve revision. My Dr says he can perform the procedure at the same time. Price will be $8000 for hospital and $1736 for his fee. Total $9736. I asked about a discount as it seems my insurance company is already paying for hospital, surgeon, anthestiga, etc. They (hospital AND doctor) are telling me no because it is two different procedures even though performed in in the same operation. Has anybody else run into this?? I expect to cover the cost difference and I am sure there are some but this really sounds like I am being double dipped.

For those that have bariatric surgery benefits with United Health Care, they now approved Vertical Sleeve Gastrectomy!!!! Hooray!!!! Here is the language from their Bariatric Medical Policy, dated 12/20/2007 that was in effect before 9/17/2009:The gastric sleeve procedure (also known as laparoscopic vertical gastrectomy or laparoscopic sleeve gastrectomy) when done alone and not a part of the full operation to complete a biliopancreatic diversion with duodenal switch is unproven due to inadequate clinical evidence of safety and/or efficacy in published, peer-reviewed medical literature. Here is the language from the UHC Bariatric Medical Policy dated 9/17/2009: The …

Are there any Chase Bank employees out there??? I would really love to hear how the insurance process went!! PLEASE let me know!!!

I have been overweight for all my life but I do not have the complete record of information I need information of 2006 I did not go to the doctor at all that year. I consider this a blessing but now that I am pre-hypertension - blood pressure - and thyroid problems I can't get my lapband. Any suggestions on how I can prove I was overweight for that year. I have weight watchers information would that work??? Thank you

Hi there everyone. This board has been a God send, all of the information is wonderful. I have an easy insurance to deal with, federal BCBS, my question however is for my sister in law. She has Cigna in TN and the policy that she has says WLS is not covered. Her BMI is 52, she has high blood pressure, epilepsy, joint problems, had back surgery, incontinence, fibromyalgia, and lupus. Is there any chance that she can get approval even though her policy says it does not cover the band? I have started my process and my doc says I wont have any problems (fingers crossed), I really want to help out my SIL because she is so upset and depressed. She has tried for years, like …

Well, I've not been here for about 2 weeks since my 3 little monkeys were so sick. Andy had a bad case of colds, Austin had pneumonia and Aaron had croup ahhhhhhhhhhh. They are all better now though yippeee! My insurance person just email me and said she submitted everything to Cigna. I was floored and mad because I suppose to give her my 5 year weight history tomorrow. She said I just wanna know if it flies without the weight history. What was she thinking???? She said she got the letter from my pcp today, so she decided to do it. :w00t: My BMI is 40.1 and the past 4 years was 35 -39.9. I just found out that I had sleep apnea and that is the only co modity th…

All my info was submitted to my insurance yesterday! They said it usually takes my insurance 2-3 weeks. So, now I am playing the waiting game. My pre-op diet is 4 weeks, so they told me to start it now. I hoping for an early April surgery date if all goes well!

Hi Guys, I am currently playing the waiting game with my insurance company. I have Anthem Blue Cross & Blue Shield PPO. I weigh 315 lbs and have a BMI of 49.3; although, I have no comorbidities. My first submission for approval was denied because the doctor's office made a mistake and submitted my application for surgery without sending in the required mental health evaluation and nutritional evaluation/assesment documentas that are required for the surgery. After they discovered the mistake, I was told that we would have to go through the appeals process. I was a bit upset because I didn't think it was fair that I was being penalized for something that was the d…

has anyone had any luck with getting aproved for VSG with BCBS TX is so how did you do it or how and who would I contact to work on this:confused1:

:cursing:Hello, everyone I am tryingto fight my ins compay I have BCBS TX and I am looking for people in other states that have had this done because BCBS TX is telling me the still expeimental BS and if I can prove other BCBS states are paying maybe I got a chance. Thank you all in advance

So, I am 29 years old, at 250lbs now with a height of 5ft 8in. My weight has been an issue since 2000. My BMI has yet to reach 40, but it has been over 35 since 2000. I am slowly getting more tired, back pains, ankles pains. MY blood pressure and cholesterol, thankfully, have always been good. My family on both sides have a strong history of heart disease, and high blood pressure. I have GREAT insurance with UHC Choice thru Boys Town. I have worked here for nearly 5 yrs, and have had to pay the most of $250 ever for anything. I go for the seminar on MArch 11th. I am trying to be optomistic about getting approved, but I fear I will not. I am a person who never goes to the …

Has anyone used TML (Texas Municipal League) for their surgery and their fills?:thumbdown:

I don't know if anyone else has noticed this, but every time I open the want ads, the amount of job openings in the health care field (nurses, therapists, technicians, paperpushers, etc) is HUGE compared to other fields. Does anyone know the reason(s) for this phenomenon? The salaries mentioned in the ads seem very generous with sign-up bonuses and what not. For example, a freshly minted RN with NO experience can now rake in as much as a long-time engineer or accountant, so I don't think the disproportionate number of job openings is because of RNs retiring or quitting their jobs due to low pay...

I have a BMI of 35 and was wondering what other co-morbities they will accept beside the ususal. I have I choleseral and hypoglycemic.

Does anyone know of a list that shows what insurance companies cover VSG? If not, should we make one and get it made a sticky? I would like to see a list of Companies, and a link to their obesity insurance policy, whether it is covered, or considered investigational, and if anyone has successfully appealed? I would think a comprehensive list of companies that do cover it would be good for people appealing a denial. Maybe this is just too big a task? Here?s Mine Wellmark Blue Cross and Blue Shield as of 2/1/2010 http://www.wellmark.com/ Current Policy VSG is considered investigational. http://www.wellmark.com/Provider/MedPoliciesAndAuthorizations/MedicalPo…

Ok, so I started this I was 315 pounds. I am now 175 with a Realize band. I was un-insurable at 315 and now I am having trouble finding insurance (I am one of the millions of uninsured Americans) on my own (no employer plan to join). Does anyone know what companies will approve me now that I have been banded? I don't really care if they call it a pre-existing condition, I just really need healthcare coverage.

Hi everyone, I'm just getting started on my Quest to be approved by United. I am seeing my PCP next week, who has previously told me she is on board with the surgery if it's what I want. I'd like to provide her with a sample letter of referral/recommendation for the surgery so that she can model mine after that. Does anyone know where I can find samples (I've looked a bit, but none seemed to be that type of referral), or would anyone be willing to share theirs? I can be emailed at Lizstar319@yahoo.com Thanks so much in advance! Liz

Yes, yes , yes....It's official, BCBCIL finally after I jumped through all of their hoops. Hoping for a March 18th surg date with Dr Bagnato.

Howdy y'all. I'm trying to find out the qualifications for getting a lap-band with Western Health Advantage. I know that with a BMI of 35-39 you must have comorbidities... but how many and what is/is not considered a comorbidity? When I've called and spoken with a WHA rep, they gave me the run around. I asked for and was send a Evidence of Coverage booklet, but again, it really didn't go into any detail. I spoke with my PCP and he was having trouble finding out all the qualifications. I then emailed a WHA rep and told them I was getting the run around. They told me "Contact your PCP and if your PCP doesn't know, he should contact his Medical Group." Anyone out the…

What does it mean when TRIWEST says Pending Review?

I am 5'10" and weighed 258lbs at my first office visit. I have had one knee surgery and am getting ready to do my second. My cholesterol is high, but not anything other than fish oil high. My surgeons office has all my paper work and was reviewing it wed. now its friday and I am going nuts waiting on TRIWEST!! I know it's been all of 2 days but how long do you think it will take Triwest to make a decision either way? I am so ready to start my new life BANDED!!

Hello everyone - Thanks for taking the time to read and hopefully respond. Here is my info. Insurance: Cigna Open Access BMI 39.4 Have had a BMI of over 35 for 10 years and can document it. Have 5 years of medically supervised diets (7 visits in 2005 with 6 of them consecutive - 4 visits in 2006, 5 visits in 2007, 4 visits in 2008 and 3 visits in 2009). Have copies of drs notes with their recommendations. Medications: Wellbutrin -taken for the past 5 years for depression. Metformin - have not been told that I have diabetes Synthroid - not aware of any problem with my thyroid Phentermine - gave me the jitters so quit Meridia - worked fine and lost weight …

I am waiting to hear from Triwest and if I am denied I am thinking about having a lawyer appeal for me instead of me trying to do it myself.....Anyone have any experience with being denied and fighting it?

Got a call from my doctor today saying my insurance company approved me for the lap band. Im so happy and cant wait til I get my surgery.

Does anyone on here have cigna? I have my surgery date set for dec 21 and i wondering if i should wait and see if they will cover it? is anyone in the same boat as me? Im wondering if anyone knows the code the insurace needs? is it 43775?

My doctor submitted the authorization request on 12/1/09 and it is 10 days later and I am still "pending". Tricare says it is due to it being an elective procedure and not having a surgery date scheduled so they do not have to approve within 5 days like other procedures. Has anyone else had this problem?

My insurance requires a 6 month pre op supervised weight loss program. I was on medifast for 6 months and went to my doctor to check in for weight every two months. Does anyone know if medifast is accepted by insurance companies. My insurance is Regence Blue Shield of WA. Also, what exactly does my doctor need to include in her letter. It is amazing that doctors are not sure what to put or how to make this easier for the patients. Any feedback would be appreciated, I want to do this right the first time. I don't know if I could handle an appeal.

If you're self pay, can you use Lapband surgery as a tax write off?

I called my insurance company today and asked about fills and they told me that they are covered if "medically necessary"...does this mean that they are covered or what? I am not sure who deems them medically necessary or is it just the process? please advise me of your experience with Cigna..Thanks

Hi, I was checking my status on "Mytricare.com" and this morning there was no pending authorizations in my account. So I thought, "Oh no it was denied" but I thought it should at least show it there. I called Tricare (north) and the lady told me that I didn't need an authorization. Then I explained to her that this was for lapband and there were requirements that tricare has, and she said I met the requirements and a letter would be sent, but that I didn't need an authorization. I know for all my other care like specialist I don't need authorizations that is the great thing about standard but I thought for this I would get one. Any thoughts? I haven't been able to g…

Now that I am one month post-op, statements and ‘Explanation of Benefits’ have started to arrive from the hospital and my insurance company. Although my insurance covers 80% of my Lap Band surgery, I was intrigued to know what the large amounts money, submitted to the insurance company, were actually for – they are listed on the ‘Explanation of Benefits’ under the nondescript heading of ‘Service’. I called the hospital and asked for an itemized listing of these services, which the hospital provided. Being a non-medical person I do not understand what the majority of items are, but a couple of things did catch my eye. # 1 - on the statement for my pre-o…

Anyone in the Dallas/ Ft Worth area know of any surgons who will take Tricare Prime?... I will like to have the Lapband done but, I know allot of doctor do not take Tricare Prime. Also, Did you or anyone you know have any issues on getting it approved? I would appreciate it if anyone has any info... Thanks, Dee

Hi. I am new to the world of Lap Band. I am going to a seminar with my doctor on Feb 8th. At the moment I don't have any insurance and I am looking for wisdom from all of you out there that know WAY more about this than I do. :thumbup: I live in Washington State and I am wondering if anyone might know the best insurance/plans that cover this surgery. Any information is helpful and I thank you for sharing you knowledge. ~Relynn~

Anybody here have any copies of letters of recommendation that WORKED from your PCP? I talked to my doctor today and he said he'd be glad to write me one and even said if you want to email me what you want it to say, go ahead and I"ll put it in there. Anybody have one? Or know of a site/place that I can get one? If you do, PLEASE let me know. Respond to this post, or email me at fourjtowers@netzero.net

If your insurance says it's not in the covered benefits has anyone had any luck with fighting and getting approved for medical reasons? I finally felt like I was at the point to be "ready" to go through and do this and then found out it isn't covered by Aetna. I don't have $15K lying around either :smile2: Any help is appreciated :tongue:

Does anyone know how often they review and update these medical policies? My surgeon recommended either RNY or sleeve for me and after tons of research, I decided that the sleeve was the best fit for me. THEN I find out my insurace considers it expieremental and it isn't covered. RNY scares the heck out of me. The sleeve has been out long enough (I feel) to see that it is better than RNY. I just don't know what to do. I mean I can't afford to pay out of pocket so I can either go ahead with RNY or stop everything and wait until my insurance covers the sleeve, but how long will that be? Any suggestions? On my medical policy, the last time they looked at the sleeve wa…