Insurance & Financing

Hey folks- I'm about three months into the 6 month supervised diet. I haven't lost a ton of weight, but at my most recent visit, I was asked to start using a food log. The plus side is, it has really whipped me into shape and kept me honest. The bad side is... well, it's really whipped me into shape and kept me honest. I'm nowhere NEAR 35-40 BMI, but I'm currently only eating about 1300 calories a day. On this pace, I could lose over 30lbs (or more!) before a May surgery. Will I get denied? My PCP also put me on Meridia, to help get some weight off before surgery. It's working, but I worry it will work TOO well. The WLS office said it's okay to be on the Mer…

Here is my concern. On May 1st I will have completed everything the insurance company requires. I actually have my last appt for the 6 month weight loss visits on that day. I plan to drive over to the surgeons office with everything. If it is submitted and approved within 2 weeks I wonder if I will have a long wait to get the surgery done. I really want to get it done the end of May. Some people on here seem to already have tentative surgery dates. Has anyone received approval from insurance and then the surgery was scheduled within two weeks. I know this sounds petty but I don't want to get an approval and then find out you have to wait to get an appt for surgery anothe…

Hi, I am just starting out and I probably have a ton of questions, but one that means the most... I have always been overweight, since childhood. So it goes my family is also over weight....every one of them. I never considered surgery until these past 2 months, when my sisters gallbladder exploded (3 weeks in hospital) contributing factor?- obesity My mom was hospitalized last month with blood clots, and this week with heart attack. contributing factor? obesity My dad almost lost his leg...from undiagnosed diabetes. Contributing factor? obesity I have never been so awake to my own weight problem in my life. I know I am not being too hasty, as I have spent a m…

Hello all, I'm new to this. I have been researching LapBand for about a year now and have finally decided to go through with it. I have had my consult with True Results and go for my Psych eval, blood work, and Nutrition appointments tomorrow. I am with BC/BS of CA, and wondering how long the approval wait has been for others who have/had this insurance. . I'm very anxious and ready to get this done so I can start living a much better, healthier life:smile:! -Gretchen-

I read on the medicare website that they now cover the lap band procedure- Am I right? I wanted to know if there is anyone out there that has it that can confirm it so I don't have to call and go through the hassle. Also, I am 27 BMI of 45, went to a nutritionist, went on weight loss drugs, so have a history of trying, but have only been like this for 3 years. Do you think I am going to pass through? Thanks, Jessica

I am hoping to find someone that has had their surgery covered by this insurance. I will be changing to this plan in Dec. and I just want encouragement that it will HAPPEN.,.,.,.,.,.,approval that is.!

We were approved for a medical loan through capital one through an online application. It seems like its a good start. I have the consult with the doc I chose on Friday. Does anyone have an estimate on how long it takes for the loan to come through?

Hi. I complete my six month diet under a doctor and lost some weight in the beginning but couldn't keep it off. I just picked up my records from the doctor's office and I see that she used words like "admits noncompliance" . Will Aetna deny me based on something like that? Has anyone had things like that written in their records and still been approved?

What if you don't have the 5 year history. I've been overweight for a number of years now, but I was never really sick so I never went to the doctor. Hence I don't have the weight records for 5 years. I went to the hospital about a year ago for knee surgery. It was weight related. I have a BMI of 42 now. I just moved to a new state so I don't even have my old doctor anymore. I have a new doctor now and I talked about it with him. I'm going in for a physical in a few weeks and my pcp is going to write me a letter. Diabetes and high blood pressure run in the family. What do you think my chances are of getting approved? After I get the letter from my doctor I'll b…

Hi there, I'm going to be a public school teacher this fall in Georgia, and have recently found out that lap band is not covered!! I want the surgery and feel I am a good candidate, so I don't want to be covered under the state's plan. I'm thinking about purchasing a plan with a provider outside of my job, if this is allowed. Can someone point me in the right direction? My BMI is 44 and I've been overweight for 10 years with a medical history to back it up. Can someone help?? :thumbup:

My employer is thinking of changing health benefits. As employees we currently choose between BCBS Horizon or Traditional Plan. I currently have BCBS NJ Horizon (PPO Direct Access). There is no weight loss exclusion on my current plan. I am told that they are eliminating the Traditional Plan and everyone will be on Horizon. Here is the concern: some people are saying that our present BCBS Horizon coverage could change. Does anyone know if there is actually a BCBS NJ Horizon plan that has a weight loss exclusion. I should be ready for approval for lap band in May. I can't imagine all of a sudden having a new policy with an exclusion. Are there actually alot of plans out th…

my father is a fed employee and I'm under his plan we were going to pay out of pocket because everyone told us that to get approved for insurance we had to go on a 6 mo diet and we did not want to do that so my surgery date is 1/9/09 but i now see on this board that BCBS fed does not require a 6 mo diet but in 09 will require pre certification what exactly does this mean???? oh i forgot to add that my bmi is 51 thanks in advance Liz

I have to contact Aetna with an exception letter. I qualify for the surgery and have sleep apnea and GERD. I was wondering if anyone would share a letter they have successfully used with Aetna or any company for that matter. Thanks for your help.

Does anyone have Aetna ins that works at ATT? My friend called her ins co to find out if she has to do a 6 month diet or anything and they said they would mail her a packet and didn't answer any of her ?'s. I was hoping someone here has it and can answer some of the ?'s without her having to wait weeks to get this packet. Is there a diet and what are the BMI requirements and are there any other requirements. Any info would be greatly appreciated. Thanks Karen

I posted this on another forum before I realized this forum was available... please read: I believe I met the surgeon that was to perform the Lap-band on me back in October of 2008. Since then I have met with all kinds of specialists for approval of the surgery. I had a sleep test done at the hospital. My insurance, Blue Cross Blue Shield IL - HMO had approved everything... I have/had an appointment scheduled with the surgeon for this coming Friday and I just called to confirm that they had all the evaluations needed so that when I met with the surgeon again we could take the next step which I understood was to schedule the surgery. Well the nurse informed me that d…

For those with BCBS... what has been your experience with the 6-month diet? Were you able to get banded SHORTLY after the diet ended? Meaning, did the rest of the process continue along, making you immediately ready for surgery as soon as the diet was "done"? Or did you have to do the diet, then wait another 6 months before surgery (e.g. following up with psych evals, sleep studies, etc.)? I'm getting married at the end of November, and I'm hoping to be banded well before then so I can be on the road to recovery. Thanks for the insight!

I have Aetna POS II and i called this morning and they said they do not cover the surgery. Is this due to my employer? Im very let down and tired of feeling bad........do i give up? I qualify for the surgery because of my weight but am ready to give up.:wink2:

Hey Banders! :scared2: I just got approved for AHCCCS/Medicaid and was wondering if anyone has had any luck or experience with them. I'm praying they cover it! My last insurance company pretty much told me too bad so sad sucks to be your fat ass! :thumbup: Any experiences?

Bad news..I have recently developed acid reflux. Good news...is this a comorbidity? I made an appt tomorrow with a gastroenterologist. My BMI is 38-39 with co-morbidities. If this counts as one I will use it to my advantage.

I have a question for those of you out there that might be or have experienced this situation as it relates to getting insurance approval. My BMI is 38.5 and I have GERD, hypertension, and high cholesterol. My insurance policy (which is CIGNA) states that if my BMI is less than 40, I have to have one or more comorbidities. However, further down in the policy it states that hypertension qualifies so long as it is clinically unmanageable hypertension. My blood pressure is controlled by taking medication. Does this mean that it is "clinically manageable" Has anyone with a BMI<40 got approval even though their blood pressure is managed with medications? I also take pr…

Just wondering about the chance of getting approved without the 6 months of supervised dieting? I have a BMI of 54 for more than 5 years. I haven't really done any dieting since the birth of my son. He will be 2 in April. Thanks.

My doc submitted to insurance on Thursday, they called and gave approval today!!! That's two business days!!! YAHOOOOOOOOOOOOO! My out of pocket- $3,750.... =( I was originally told it would be $2,000. So now I had to schedule surgery for Jan 22nd so I can save up the extra $1750. Ugh....

I had my appt with the surgeon's office for lap band consult. Prior to this appt I went to the informational seminar, had the psych and nutrition eval done and sent to their office. Next week I have my second appt with the primary for supervised diet. Anyway I have several co-morbidities, the office seemed certain that we would be doing the surgery at the end of May. They gave me a checklist of a few things to get to their office: most recent bloodwork, the letter and notes from supervised diet and pre-op packet and physical filled out by primary and sent to them within 30 days of surgery. I told them my last 6 month appt was May 1. After leaving the surgeons office I bec…

As I stated last my insurance will only cover $15000 total for weigh loss surgery. I got a estimate today for $23000. I was told by the hospital that they have a agreement with my insurance for a discounted price. The problem is they told me they could not tell me what that price is because it is a agreement with the insurance company and them. So I called my insurance company and asked them. They also stated I was not "privileged" to that information but they have entered agreement with the hospital for a discounted price. I asked why I can't get that information and they told me it was confidential. So I became a jerk and told asked them what right do they …

Wondering if anyone has had luck getting their insurance to pay for fills when they don't cover WLS? I saw one post that said they could charge for an ultrasound, injection and office visit and the insurance co. would pay. I'm having surgery with Dr. Kirschenbaum on May 14th and would like to be able to get my fills close to home (and payed would be nice).

I am looking for a support person that lives in Newport News. I am going for my first consult today with my family Dr. to see what he think about me having Lapband done. I have a 43 in the BMI, I am on 35 yrs old. I have two children that I would like to see grown up and have children themselves. I am hoping my Dr. can help me with all my questions and with the insurance company. I would like to thank all of you that have put your experiences out here, this has helped me alot and I will continue coming out here to read more. Wish me luck this is the beginning of my new journey "I hope".

Does anyone know how long it takes BCBSTX-FEP to determine approval/not approved once paperwork is submitted and is there a way to check the status online?

Hi, Has anyone encountered this situation: My doctor's office called me in december 2007 (before my surgery) stating that I was pre-approved (they had written to the insurance company). Then I had the surgery in February 2008 and the insurance company took forever to respond and then once they did, they said they needed more information. I called to find out what and they said "medical records." I called the Dr.'s office and they said that Blue Cross Blue Shield Federal Employees Plan doesn't really "pre-approve" and they never go an actual "pre-approval" just a letter stating that the procedure was covered. I already knew that ! I just about freaked out. The doct…

Ok, here is my dilemma - I am in the process of completing the 3 month multi program that Aetna requires. Part of their requirement is having a BMI over 40 (or 35 with co-morbities which I don't have) for the previous 2 years. Ok, so this is where it gets kind of tricky for me. I originally was going to start this process at the end of last year but was afraid they wouldn't approve me due to my BMI in 2006. I am a yo-yo dieter and in 2006 ONLY I had a normal BMI. Every other year it has been over 40. (That whole thing irritates me, I think they should look at OVERALL history, not just 2 years) Anyway...so now it's 2009 and I will be submitting for pre-approval at t…

I was hoping someone else out there has the same insurance I have and may be able to give me some advise.. It is Anthem Blue Cross Blue Shield HSA plan.... I am just starting the processes and not sure what the first step should be.. Thanks

Hi everyone , Before making the decision for Lap-Band surgery my BMI was 42.6. I then went on the weight loss pill phentermine for a year and lost approx 20 pounds with 4 days of hour long cardio/kickboxingand have been on a pleteau so my DR and I decided maybe lap band is the way to go . I have been on the Aetna 3 month plan and I started on Nov'08 , When I met with the surgeon he gave me a surgery date of 3/30/09. My BMI is 39.6 so as required with Aetna I need a co-morbidity ... Needless to say I do not have high blood pressure nor diabetes etc.. I do have PCOS but I am aware that does not qualify me for much . I just received my results from the sleep study and it sh…

I started this whole procedure back in Mayof 2008. I had done ALL the pretesting and was basically waiting on the final approval for insurance... then I lost my job...and didn't have insurance for a total of 6 months (out of work 3 months, then had a 90 day waiting period at my new job) So I finally get insurance w/ my new job and call to get the procedure "back on the books" and am told I now have a ONE YEAR pre existing condition waiting period... Even though I started this procedure BEFORE I lost my insurance? ????? So now I"m going to have to go through ALL of the pretesting AGAIN at the end of this year. So sad !!!:laugh:

I've been reading some of these posts and they say that you actually need 7 months of Dr. supervised weight loss? What? I was told by my insurance BCBS of IL and by my patient advocate from Day One Health that I only needed 6. Some of these posts say you actually need 7? That the first month doesn't count??

I am trying to get everything ready to submit in May to the ins co. I am now hearing something about "exercise" or going to a trainer. What is all of this about. I do have records of a gym membership in the last 2 years but I have not gone to a trainer. Are people actually going to a trainer and having a report sent on their behalf?

Does Cigna in Maryland cover the Lap Band or at least some of it?

Has anyone every had surgery for reflux/hernia repair as primary and had lapband as secondary procedure to cut cost of lapband?just curious and trying to weigh all options.

Hello everyone I'm going thru the process right now and I would like to know what I am going to have to pay for myself. I have looked all over this web site and heard different things. I guess what I am looking for is anyone in the Memphis area on Tricare Prime to help me with this. I will be seeing Dr Virginia Weaver. Thanks for all your help.

I have B/C B/S OH and they have denied me because my BMI 39.4 and I do not have two (even though my policy does not say I need two) medical conditions. They did the Peer to Peer and denied again. I wasn't sure how that works since the only thing they could talk about would be the paper work they already had when they denied me the first time. Too much stress so I waited until after the holiday to start going 100% with this appeal again but I don't know what I can do. My dr office is sending me a package so I hope that helps me understand. My dr office said to keep calling my insurance, but what am I supposed to be saying or asking if I call daily??? My BMI is now 40…

I recently found out my insurance Aetna, will pay for bariatric surgery. However, it isnt cheap. I have an $1100 deductible and they will pay 80%. My max out of pocket is a whopping $4000 (on my husbands plan, i believe it is $1500 max and that $4000 is for our whole family--so, YOUCH!) So, my questions are: Does that $1100 deductible count in the $4000? Also, would 20% of the surgery equal up to $4000? could it potentially be less than the $4000 max-out-of-pocket or should I just assume that I will be paying $4000 for this surgery? OR--would it really be $5100 if the deductible isnt inlcuded in the $4000? Thanks a lot. Stacie

I am gathering everything. I have all my weight watcher books with weights from previous years. I made copies to submit along with everything else. Does it hurt to show the ins. co that when I joined(& rejoined several times) weight watchers my BMI was between 35-38 at all initial weigh ins. Then as I followed program and lost weight I did go down to a BMI of 32-35. Of course I always gained all the weight and then some back. I have weight watcher weigh in books for 2005, 2007,2008. I have just started my 6 month doctor supervised weigh ins. The first weigh in was December and the BMI was 39. I anticipate that the BMI will be 35 at last weigh in. I have heard that if …

How long did it take to get your approval after all your paperwork was submitted?

So, I got all the info from Aetna (my insurance) for what it takes for precertification. And, confirmed that I don't have an exclusion. Based on the precertification rqmts, though, I expect that this will be a fight for me to get approved. So, I'm wondering if it is better to apply for precertification before the 3 or 6 month diet to see what they are gonna fight me on. Or, are you supposed to wait until you THINK you meet ALL of the rqmts to submit your first precertifcation. The thing is that I would not want to do the 3 or 6 month diet unless it is going to help me get insurance approval. If I can't get insurance approval, then there's no point in doing that diet…

I have all my six month appts for my monitored weight loss set up. The first appt was Dec. the last is May. I am now hearing that they will only count this as 5 months. The first appt actually counts as your initial weigh in with your doctor and not as a month of weight loss. Has anyone had this problem. I have BCBS NJ. I just want to have everything right before it is submitted. I want to be approved the first time around.

:unsure:My husbands company has Anthem BCBS of GA. We live in Cincinnati Ohio. Anthem states that his company does not cover weight loss surgery.? Is there anything we can do? He needs this surgery. Also, anyone in the area know a good sergeon or any information would be helpful! Thank you for your time! Molly

My insurance is MedCost, but it is managed by a cooperative benefits organization (my husband works for a co-op). They use a third party company to handle specialized care (wls, infertility, cancer, etc) and the third party company determines if your case warrants surgery or not. After they make a determination they send a letter to the insurance company telling them their findings. I'm not sure what happens after that, if the insurance company does any further review or if they just accept the decision of the third party company. Has anyone else had to go through something like this? Thanks, Tammy

:confused: Hey everybody! My husband and I are going through this together. Our last appointment for the 6 mo. plan is Jan. 20th and I get more nervous by the day. I'm worried about insurance not wanting to pay for 2 surgeries. Anyone have experience with this? Here are our stats. Me: 40BMI @ consult, severe sleep apnea, psych eval (done), dietician appt. (done), and 11 lbs. lost during 6 month diet (currently 39 BMI). My husband: 44 BMI at consult, diabetes, high BP, fatty liver, psych eval (done), dietician appt. (done), 15 lbs. lost during 6 month diet. I think my husband's good to go, but I'm nervous about my approval. Have any good info or tips for us? We have Aetn…

I was wondering if anyone else has had this experience and would be willing to share. I have to pay 1/2 of the cost of my surgery, which will be approximately 10k out of pocket. I'm willing to do that if I have to. I've come to terms with it. However, my insurance company won't let me do a pre-authorization for my surgery. The way it works is I have the surgery, then my doctor sends in all of my information and says, "Please pay for this". Then the insurance company decides. Did anyone else have to do this ? Have any of you been denied ? Now...I'm willing to belly up 10k to the table, but to turn around and potentially have to pay another 10k, I don't think I could …

...to find out if you have been approved? I have gone to the claim status page and all that tells me is about previous doctor's visits (not the surgeon, but my PCP). Or do I have to just call them to find out? I am just being impatient and want to bug somebody and not have to wait over the entire week-end to find out!:confused:

I'm trying to appeal to BCBS of Oklahoma for the lap band & am interested in BCBS's coverage of it in other states...anybody out there know???

I called fed BCBS Monday and talked to a rep about surgery. I specifically asked her if I needed to prove that I had followed my docs weight loss plan for 6 months and I was told that fed BCBS doesn't need to do that anymore. So, I called Penrose and set up an educational consult. Today I was called by Penrose and was told she had recieved a memo that said I needed to follow a 6 month plan. So, I called my doc, set up an appt and they proceded to tell me I didn't need to. So I turned around and called the insurance company again and they again told me I didn't need to. So I called Penrose again and left a message...talk about confusing! I went ahead and kept my doc appt…