Insurance & Financing

Are there lots of policies that have exclusions? Is this the norm or rare? I have BCBS NJ Horizon/PPO/Direct Access. Right now we do not have an exclusion. My employer is moving all employees to Horizon in July, they will be eliminating the traditional plan. I am afraid that they may make some changes to our current Horizon plan, like an exclusion for weight loss surgery. I am wondering how many people have encountered exclusions on their plans. I will be ready to have everything submitted to ins May 1st. I am worried with changes around the corner that I might not get an approval in time.

I just received a call from the Dr's office to say that I was denied . She told me they denied me due to my BMI is 39.6 and no cor-morbidities .. Mild sleep apnea is not enough and they do not consider PCOS . She said she has to give it to the DR and see if he wants to appeal . Is that my choice or his ? Also my PCP had me on Phentermine for over a year now and since I had to be on the PREV PAC (H PYLORI) I stopped taking the Phentermine and I have gained 7 lbs in 2 months . If I am not on these pills I will just gain .. I am so upset , What should be my next step... Weight currently is 203 at 5ft . I am so upset I cant think straight ... Not sure what to do now

Hi All, TriCare(Standard) offically started processing my request on the 21st., I just checked the web site and it has been approved as medically necessary:party:. However the date of service listed is 3/5/09, hope I really don't have to wait that long.

I am so upset , not to mention hurt . I did my 3 month diet plan with Aetna Pos II( I also have Aetna HMO as my secondary), and my surgeon scheduled me for 3/30/09.. I do have sleep Apnea and BMI is 39.9. With Aetna POS II you need to have a BMI of 40 or more for two years or 35-39 for two years with a co-morbidity. I was perfect . I was originally at a BMI of 42.4 with efforts I was able to drop some punds and have been at my current weight for months . I also have PCOS so it is just that much harder for me to lose. I requested a copy of what my employer covers and it states that they only cover gastric that banding is not covered at all. I am so upset and hurt . My only…

Hello all, I have been completing my requirements for the lapband put forth by Aetna. During this process I have been reading the posts on lapbandtalk.com regarding Aetna, their process, denials, appeals, etc. The posts were about 50/50 on who was approved and who wasn't, who had to got through a lot to get the approval and so on. I was slightly worried, but still keep the hope that I would be approved the first time, even if it took a year. I have to say that I am very impressed by Aetna now that my surgery has been approved. I started the 6 month supervised diet in June, the last appt. was Nov. 26th. I went in to my lapband doctor on Dec. 2nd, turned in my records for…

Hi, does anyone know if Masshealth covers lap band procedure? Thanks!

Ok, I am new to all of this but please bare with me. I am so worried about getting approved for lap band through blue cross blue shield of arizona. I have documents from the past 15 years (jenny craig, weight watchers, and diet doctors that give meds) but my BMI is only 38.7 and I don't have any other medical problems. Do you think I am going to be turned down because their rules are 40 BMI or less than 40 but with other factors? I dont have any other medical problems that I know of.:mad2:

Hi all, I went to see my doc regarding the LB surgery and she said she was pretty confident that she could get me approved as she was good at doing all the paperwork and whatever was needed. Little did she know my insurance (aetna) would cover the surgery after exceptions, which was fine, even though I am healthy, my doc was not worried and said she knew how to get it covered...BUT my employer will not cover it. Gee thanks job. I HATE my job right now. Ive been here for 5 yrs and had I known 5 yrs ago that I wanted this surgery and they did not cover it, then I probably wouldnt have taken the position, as I had other offers at that time. This SUCKS, and at 231lbs, 5'2…

After your loose your Job due to down sizing and you go on Cobra Insurance for a short while. How are they about fills and Dr visits for the Lap Band. Anyone have to deal with this issue. This is a weird issue the band has been a curse to my life more that a wonderful thing. Getting small is great and I am doing wonderful but the fallout is really getting crazy. The whole loss of Job ties back to a% of this. Now before someone says they can't do that. I said a % ties back that this. Anyway back to the Question. anyone got a answer??

How many calories were you reporting on your 6 month BCBSIL diet? I have been doing everything to a T to their guidlines they have posted. I am just worried about getting denied. It is getting close now to the end of my 6 months.

Had a evaluation today and doc thinks I need more therapy. She thinks that after having lap band that I will use other things other than food as a comfort....NOT!! My husband and all of my family laughed when I told them. I have cradentials to back me up when I say I do not have an eating disorder. I do not do drugs or drink. I told her I will not go further with therapy. Does anyone think my insurance (BCBS of MN) will deny me? I am pre-diabetic, high blood pressure, stess incontenance. HELP!!

New to the forum and find it very helpful! I've been thinking about getting the Lapband for the past three months. I finally went to a seminar to see what are the first steps needed to start the process. I called my insurance company (United Healthcare) and found out that they do cover the surgery with the normal guidelines. At the seminar I found out my BMI was 54, I have no co-morbidity and that with my age I was a very good candidate for the surgery. The question I have is.....that most of the weight lost surgery programs here in Ohio want you to pay a program fee. Some starting at $300...$500...even up to $800 non-refundable fee, and has to be paid before they will ev…

I received the letter of rejection today citing the 6 mo. non-surgical weight loss program as the reason. I did WeightWatchers and lost 17 lbs. My surgeon has all the documentation, so I will check it out further tomorrow. Maybe it just didn't get sent in. Hope it can be salvaged by my 3/03/09 surgery date. If I lose that, it's about a 6 mo. wait for a new date. Can't say I didn't expect this, given what I have read and heard about BCBS IL. I am committed to this surgery and will not relent. Whatever I must do, I will. I'll keep you posted...Dan

My paperwork should be submitted to my insurance company either tomorrow or Tuesday and I am feeling kind of discouraged because of the patient advocate at my surgeon's office. My insurance (UHC Choice Plus) requires a BMI of 40, and weight history for the last five years, and if you don't have the 40 BMI, you have to have 35 plus two comorbidities. At my initial consult I had a BMI of 40.5 and over the last five years I don't have a 40 BMI but it has definitely been over 35. Fortunately I don't have any health problems but I know if I keep down this road I will definitely develop problems. Anyway, the woman at my surgeon's office keeps telling me that my insurance is…

Has anyone been denied because of an exclusion to WLS, applealed, then denial reversed...I thought I'd ask before I put alot of work into trying to get approval.

I got my approval today!!! No out of pocket cost for me. I can hardly believe it. I will have a March surgery date. I going to start my pre-op diet tomorrow, just in case I can get in on a cancellation. I might be one of the few people that likes protein shakes. I am soooo Happy I can barley sit still to write this. Anya:thumbup:

Cigna approved my lap band surgery Hip Hip Hooray! I am going to meet the surgeon on February 26. I cannot wait :smile: By the way, I have to be on liquid Protein diet + one lean cuisine meal for 2 weeks then 4 liquids diet (no solid) for the week before surgery. Any advice on which Protein Drink will not make you hungry that much? What I need to prepare before I see the surgeon and the dietitian? Any recommendations is greatly appreciated. Thank you, Alisa

I am going to have a EGD done soon to see if i have reflux and a hiatal hernia.I am pretty sure I do.I am hoping that if I do i can get it repaired and including the lapband as secondary.My insurance has an exclusion on WLS.

Hello Bandsters, Can you please comment on the following questions regarding insurance requirements. 1) Psychological Evaluation and clearance - What is the visit like? What kind of questions? What is a MMPI? 2) Cardiac clearance - What happens at this visit? Did your PCP do a referral? How do you go about getting this documentation? 3) Documentation of a normal Thyroid function - How do you go about getting this documentation? 4) Pulmonary clearance - How do you go about getting this documenation?

Hi guys, I'm looking for info regarding employees of TWC who have UHC. I have UHC Choice Plus EPO, I have a BMI of 48 but no co morbidities, no supervised weight loss attempts and I never tried to lose weight through something documented like Weight Watchers or Nutra System. The UHC rep I spoke to stated that I meet the initial requirements but said that there were probably other considerations when a board reviews my claim for approval. There is no way that I can pay for this out of pocket and am trying to improve my changes of approval. Can you please describe the process you had to go through in order to get approved for the lap band surgery including any informat…

I am really working hard to get all my ducks in a row for an approval in May. I am counting on approval based on medical necessity due to co-morbidities. I take medication daily for diabetes type II, hypertension and high cholesterol. All is controlled and stable with meds. I have also just begun seeing a podiatrist for bone spurs, they are now giving me orthotics and I have a sleep brace. I am also now seeing a gastroentrologist for GERD. This just developed three weeks ago and I had an endoscopy today. I was thinking it would be in my interest to have both of these drs (pod & gastro) also write a note on my behalf to support medical necessity. They may not be co-mor…

Reason being, I have a date for 3/4...ppwrk not submitted yet to atena,surgical corniator is very sure of herself,I have a appt for 2/24 to come in to sign ppwrk,I was informed to bring a witness to sign also a little confused..

We are going to our first visit with the doctor today for my husbands surgery. We have an 18mo waiting period for weight loss on our insurance. So, we decided that he needs to have it done first. Me? I have to wait another 18 mos since I was just added to his insurance. I am so excited for him, but so frustrated that I have to wait so long. I have always been a big girl. But on top of that I have horrible cholesterol levels. We have three beautiful kids and I want to live longer for them. Not much worried about getting fit and skinny. Although that is a plus, but I just want my heart and body to allow me to be here to help and see them grow. And of course, like al…

Hi i heard something today, that Tricare was no longer covering lapbands. Im in Europe so i have tricare overseas. My firiend said the doctor today told her they weren't covering it as of January 1st. 2009??? I don't know if it will affect Tricare stateside. Does anyone know anything about this????

Ok, I have United Health and I am one appointment from submitting all information to the insurance company. United health has issued a case nurse advocate to help me with the process which has been wonderful. But I have a question: United Health Care will pay 20.000 of my procedure, but I also have paperwork that says this. Deductible 250.00 (which had been met) 90/10 Out of pocket 2000.00 So my question is this, will I owe anything above 20.000 , or the out of pocket max. Thanks Julie

five years in a row? I need this for Aetna, but I'm not sure what to do with it. I did go in 2003 and 2004, but I was pregnant both years. Any thoughts?

Hi! I'm wondering if anyone has any information about what health insurance companies may cover some or all of the surgery costs? I know OHIP doesn't cover the cost, but I have group health insurance through my work (manulife financial) and I'm wondering if anyone has had any success in having their group health insurance cover the costs? Thanks, Meghan

Has anyone here had experience with Calpers Blue Shield HMO? Per instructions at the seminar I attended last night, I called my HMO to ask some questions about coverage of weight loss surgery. The answers were all what I had been led to expect -- BMI of 40-49, no co-morbidities; BMI of 35+ plus one severe co-morbidity, no other documentation. Here's the catch -- in order for the co-morbidity to "count," it must be resistant to "intensive medical therapies." So, in other words, if I have HBP and diabetes that can be controlled by medication, these co-morbids cannot be used to justify weight loss surgery. This makes no sense to me -- I thought insurances approved WLS to g…

I called Cigna today and they said my lap band procedure has been denied due to lack of 5 year weight history. I told them that I gave to my insurance person but may be the fax did not go through. I did fax them myself just now. I called my ins. person and told her this and she said oh I forgot to fax them. I have to wait another week now so hopefully, I will approve soon. Alisa

So i am told that LB is not covered by my ins then im told that it is covered but there are stringent req. then im told that because my employer has choosen not to cover the procedure that it isnt covered. :cursing:i just got off the phone with uhc and they told me that my employer has choosen not to provide this coverage with their policy. i asked them to send my benefits coverage etc and they tell me that they can i have to get that from my employer that they arent even allowed to tell me what benefits i have:cursing:...yet they just told me that this is not a covered benefit..so i go to our hr person who really does nothing more than payroll and she tells me she doesnt…

After going through all the tests, being pre approved, having the surgery and had my first fill. Now after 3 months post op, my insurance says that the paperwork from the hospital wasn't filled out properly so they haved denied all proceedures! What the <%$*&!! I have always checked in advance with my insurance and the care coordinator before proceedures to make sure that each process was approved and got confirmation and approvals. Now, since the insurance company claims "We have previously requested additional information regarding the listed claims. The requested information was either not received, or received incomplete, within the 45 days specified u…

Hi everybody, My husband and I were approved yesterday, and I couldn't be more excited. We have Aetna Select Open Access POS for our insurance. We just made sure to stick to all their requirements in the allotted time, and Bingo-approved! So, to anyone having doubts "Just hang in there and follow all the guidelines to the tee and you'll be fine". I took 2 weeks for the approval and I'm scheduled as early as next week for surgery. My husband has to do the Optifast, so he's not scheduled for 3 weeks. I was so nervous throughout this long process and I never thought I'd be one of the people writting one of these threads, but here it is. I'm stoked! :cursing:

Anyone have Boon? My husband is the employee and I am the dependant. My doc mentioned that there may be a way around the whole 18 mo waiting period thing. Since he has passed his 18 mos and mine has just started. Anyone have any idea if this is true?

You guessed it, 6 month diet. I have done the following and do not know if I should push the submission to the insurance company after pysch eval. I have BCBS of Texas. They indicate that WW is acceptable. I have done the following this past year. 11/07 dr weigh in talked about surgery 12/07 wieght/BP check w/nurse and went to dietician 01/08 wieght/BP check w/nurse 03/08 joined WW and at same time had Dr complete medical necessity form for health care spending account reimbursement. On it he indicated obesity etc and need for lifetime ongoing commitment. Sill going to WW since then, so have a little over 10 months, but did not weigh in monthly with dr. 11/08,12/0…

My insurance has an 18 mo waiting period. I do not want to wait that long, but I can not afford the cash payments. Does anyone know of an insurance company that will cover the Lap Band Surgery and that has a short wait time, or they accept a letter of insurability? Pls, Pls, help.

I am still struggleing (sp) with my ins company i was wondering if anyone here who works for sava and has uhc has been approved and if it is something that is covered. so far ive been put on hold for a thousand times and been given pretty rude service etc ...can anyone tell me if they have had their surgery approved while working at sava and has uhc before i go wasting another 6 months? please help! thanks

I'm so happy - the surgeon's office just called me and I'm approved! Surgery is March 9th and I'm thrilled to begin this new chapter in my life :tongue:

I've got a couple more months of my 6 month supervised diet left. I've been jumping through all the insurance hoops and think I'm on track. I'm just curious if anyone who has Cigna insurance has been approved recently? Was it a hard process, or if you fulfilled all the requirements did you get approved right away? Just curious what kind of experiences you have had if you are under Cigna. I just keep being told Cigna is about the most difficult insurance to get approved through. So I'm a little nervous!

My surgeon's office informed me that BCBS and this surgery (Lap band) carries a global charge meaning that there is a $50.00 charge for exams and $100.00 charge for adjustments. Customer service with BCBS "thinks" this is associated with the basic plan not standard. I could not get a real answer from them. Anyone ever hear of this? Initially the bariatric center said exams and adjustments were free for a year but due to this global charge I'll have to pay for them.

I called my insurance today (United Healthcare) and Lap Band is covered at 90% which is awesome but then I was told I have no Bariatric Resource coverage, which I guess is just a service some employers pay extra for, it covers having a team find you a doctor and I guess they work with you and help you understand the procedure, aftercare, etc. I'm guessing this is no big deal because I have already found a surgeon close to me (1 1/2 hrs drive away) and I'm sure he will give me the info on the surgery, etc right? And this surgeon is in my network so there shouldn't be any problems. The question I do have is; when I asked what the guidelines were for the lap band all the la…

Hi, I am from Louisiana and I have Medicaid for my insurance. My question is, what are the requirements for Louisiana Medicaid Patients? I have read up on requirements for other insurances, such as a 6 month supervised diet, tests, etc. But I cannot seem to find anything on my insurance. Does anyone know? Please advise. Thank you. :w00t:

Hi does anyone have BCBS of Texas? I was wondering what your experience has been with them.

I have UHC and live in Northern Colorado. I was wondering if anyone out there who has UHC can recoomend the doc they used. I am starting to research doctors that my ins may cover, i thought that my ins wouldnt cover but now there is a possibility that they may so i thought i better start researching docs in the event that they will. any suggestions and/or experiences would be helpful thanks.

hello ,i have been big all my life now at the most i weigh in at 430 lbs 5 foot 6 inch male so im very over weight so i had made up my mind to get a band got approved from my doc and a heart doc , was going for my class on the bad and i got laid off from my job so now no insurence to pay for it nothing i need help to have this to save my life but i dont know what to do now if i take a lone im not making money to pay it back and they say i make to much to get mediacade so i dont know what to do please help thanks very much

If you go to your PCP for your physician monitored weightloss, then does Aetna pay for those visits normally? Or, is it one of those deals that the visit has to be coded as for weightloss and they won't pay those codes so its not covered? I'm trying to decide if I should go to my PCP for the diet or go to my surgeon's office. They offer a 6 month program for $750 that covers what is needed for the physician supervised weight loss. They also say that it facilitates approval to go through them (probably cause they know exactly how to document it). BUT, if I only had to pay my co-pay ($20 each time) to my PCP, I'd rather go the cheap route and go to her for the weightlo…

I don't have full blown diabetes but I have pre-diabetes. I was on metformin until I got pregnant and then I was breastfeeding for a year and couldn't take the medications. Now I am getting back on metformin and also cholesterol medication but I know high cholesterol isn't a comorbidity. I had gestational diabetes during pregnancy and was insulin dependant even though I followed the eating rules perfectly. My dad has diabetes and I'm sure I am headed that way eventually if I don't do something about it. I have a feeling though I am going to get denied. Any thoughts?

Has anyone done their surgery through insurance with Beech Street. I got denied for coverage through the surgery but I wanted to know if anyone got denied and appealed or wrote a letter. Please help me I need info. My BMI is 44.41 and I have no comorbidities. But I am 19 and trying to catch it early.:thumbup:

I have been approved by my BCBS MI insurance but now I am waiting on LapBand approving my insurance. My doc's office said this is something new for them. Has anyone else had experience with this. I have not heard of a medical supplier needing to approve an individual insurance before.:confused:

I want to know who's insurance covered the surgery for those who have a bmi over 42 and no comorbidities. I have a BMI of 44.41 and no comorbidities and my current insurance wont cover it so I am looking to switch to one that does. Otherwise I'll have to self finance. Responses to those in my situation beofre or now would help. Thanks.

I have Humana. I am self insured. My surgery was approved after meeting all the qualifications BIM over 40, Psych exam, Dietitian and a 6 mo Dr. supervised diet. All of which took almost a year. I had my surgery performed on 9/15/08. Now the surgery has still not been paid for. About 5 days after surgery I was sent a letter that stated that due to a diagnosis code that was used. My medical history for the past 5 years was needed to validate the claim. In short after many many phone calls later. It comes down to the fact that I gained 50 lbs from the time I had originally taken out the insurance and the time the surgery was done. My BMI was lower when I took out the insura…