Insurance & Financing

Husband is federal employee and we currently have GEHA for insurance. Husband wants to switch to MS Federal BCBS next open enrollment in October or November. Looking for any and all information regarding having surgery through this insurance provider. I have a BMI of 40 with minimal comorbidities; never been diagnosed with diabetes or hypertension although both are very prevalent in my family. Will BCBS approve under this scenario? I am trying to determine if BCBS is "better" than GEHA and whether or not we should change. I am leaning toward switching. I look forward to any and all information you have regarding the above. Thank you very much!!!

I thought I would share some research articles for people that are needing to put together appeal letters. I got them off of springerlink Obesity Surgery Journal

OK, so I've done the required psych eval (approved), and i'm 1 week from finishing the 6 month diet. I've only lost about 12 lbs or so during this time. Anybody have any problems getting approved with bc/bs mi ppo?? I am going to get the money for my deduct/copays from my 401k and I want to start that paperwork, but what if I'm not approved?? As the time gets closer, I keep getting more nervous and wonder should I really go through with this. If you've dealt with this insurance please let me know what your outcome was. thanks

Hi everyone! So my surgery is scheduled for next thursday the 28th. After the insurance coordinator submitted to bcbsil on a thursday I called on monday to check and they said they haven't received anything. So they actually called the center to tell them and the coordinator re-faxed everything. 2 days later I was approved! I have been on a liquid only diet for a few days getting ready for the surgery and have already lost 6lbs in 2 days. My advice to everyone trying to get approval is this: Don't assume anyone is going to do their job properly and be uber dilligent. I went to the center with my paperwork and went over every single page with the coordinator and eve…

My policy w/ anthem bc/bs does specifically state it does not cover wls regardless of the reason. I just wondered if anyone every appealed this and what result did you get.

My husband just got new insurance through work -United Healthcare Illinois Choice. I am reading through the exclusions and it states that that Surgical and non-surgical treatment of obesity is not covered. Does that mean WLS is a treatment or does that mean something else. I know it is probably a stupid question. Just hoping it keeps a door open of WLS surgery.

I had Lap Band in March and it was covered by my insurance, Aetna, including fills. Unfortunately, my insurance was through my old employer via Cobra, so now I need to get new individual insurance. I've been turned down for new insurance already by a few plans , including Aetna, because I need to be one year post-op. I am very nervous now about not having coverage and had no idea this was going to be a problem. Does anyone out there know of insurance plans that cover us after surgery? Thanks!

Hey all! I visited my PCP in May to talk to her about the lap band and she referred me to a surgeon to talk to. The surgeon she referred me to was not willing to work with me because I have Cigna insurance, so I had to seek out other resources for the time being. ANYWAYS...my real question is...while I wait to meet a different surgeon, I have been doing Weight Watchers for the last couple of months as part of the six month weight loss plan requirement. Cigna says WW's is an acceptable program as long as it is conjunction with a physican's supervision. Does that mean I have to visit my PCP once a month to "check in" or can it be every couple of months? I haven't been…

Doesn't anybody have Blue Care Network(hmo) of michigan? I was hopefull someone would be able to tell me if as long as my doctor is okay with the surgury I would not have to wait 6 months. Does anyone have any info?:confused2:

I'm sharing my experiences for those who have Blue Cross Blue Shield FEP so you don't encounter the same horrific experience I am now going through. I had my surgery "pre-approved" which was actually simply a letter staing that it was an approved procedure assuming I met medical necessity (this is all the insurance would provide). Well, after the surgery, the insurance determined that they didn't think I met medical necessity. To make a long story short, I have hired Obesitylaw.com to help with my appeal and they say I have a really good chance. In my discussions with Kelley Lindstrom she explained that the doctor's office screwed up by not designating the procedures …

I called customer service a few times last year and was told that wls was totally excluded from my policy. Employers choice. I called the other day 08/15/08 and was told it was covered if medically necessary. I went to anthem.com to review my coverage plan and it states that wls is excluded for all purposes. I again called customer service today 08/19/08 and they told me it was excluded. I still plan on consulting w/ a surgeon about this. I will try to appeal if I get denied. Does anyone else have this plan??? Any luck w/ exclusions or appeal process???? anthem bc/bs ohio blue access ppo

I was scheduled for my surgery prior to getting labs, psych and nutrionist. I have since completed all of these, I am waiting for the psych to get to the surgeon. I was scheduled for my suergery for Sept. 9, 2008. This was basically 4 weeks from my appointment to my surgery. I go for my ekg and final lab work 5 business days before my surgery and start my 2 week shake diet this Sunday. I asked my surgeons office if we are pushing it by scheduling so close and they said that Humana regualrly approves easily and within 3 or 4 days. I guess its that part of me does not want to start the shake diet to then be denied, delayed and have to prolong my time on the shake diet. Any…

I need advice, I am self pay & my insurance doesn't even cover the phsyc evaluation. My Dr has a phsycologist he uses but they will charge me $300. Does anyone know where I could get this done & have my insurance cover it. They won't b/c there is a written exclusion for obesity.

I got a call from my PCM today telling me that TriCare had contacted her about my referral, saying I was supposed to be going to Walter Reed, not a private civilian doctor. WTF, TriCare? THEY referred me to the civilian doctor. I have the letters they've sent me (as does Dr Currie) and on mytricare.com, Dr Currie is listed as the doctor I'm referred to. GRRRRRR. I'm heading over there in the morning to get this straightened out. :wink2: I knew this was going too easily.

Next year i will be graduating from school. I plan to pay for lapband out of pocket. My yearly salary starting out will be ~$40,000. I don't know what my take home will be. I'm not married, no kids, my only debt is my college loans (in excess of $100K but can and will be deferred). Is it reasonable to think that I can afford the average monthly payments? Should I wait a few years, save up money instead of getting a $10000 loan (and pray the economy is better?)

Anyone ever been denied based on the psychological evaluation? If so, what kind of questions did the doctors ask? (cross-post in Gen. Discussion)

I just got yet ANOTHER new insurance. Can anyone tell me of their experiences with Blue Cross Blue Shield of MA? Thanks

Hello to all! I am both excited an nervous about this whole process. I began this journey in May (the 15th) to be exact. I have had all the required tests done. At this point I am waiting for an answer from the insurance company. Currently, my BMI is 42.3, so I am really ready for this, I have no comorbid condiditons. I have been at 39.7 or more for the past 5 years. I have BCBS of RI and my question to all of you is how stringent are they? Do they automatically deny the surgery? How difficult is the appeal process? Any help, suggestions will be greatly appreciated. Thanks!

Well, basically my new PCM called me a liar. She said there is NOTHING in my medical records to indicate I've ever had Hypertension or high cholesterol or that I've ever been treated!! WTF?! She wouldn't put me on meds and referred me to the HAWC even though I've already seen a nutritionist. There is no record of my weight loss attempts according to her. I was arguing and bawling my eyes out! I'm going to the medical records dept. today to request a copy! How can that possibly be?! So I'm a fat and lazy liar according to my PCM. I've been crying since I left the clinic! I don't think I'm able to stop. I called my surgeon's nurse who is GREAT and told her to go…

Cigna has revised their coverage terms for bariatric surgery as of 5/15/08. They now require 24 months proof of obesity. Also looks like they now accept Weight Watcher if done under supervision of a doctor. Optifast® are acceptable alternatives if done in conjunction with physician supervision and detailed documentation of participation is available for review. For individuals with long-standing, morbid obesity, participation in a program within the last five years is sufficient if reasonable attendance in the weight-management program over an extended period of time of at least six months can be demonstrated. However, physiciansupervised programs consisting exclus…

I live in Florida and as most Medicare patients here know is that Medicare requires 18 months doctor supervised diet before the surgeon will even see you. Well when finding that out about a year a change ago I decided to look to other states to have the surgery. I choose NY because there is no requirement. At that time gas and traveling were cheap. I am almost done doing all the test the doctor in NY requires. My mother had asked me to call again in Florida to see if the 18 month requirement was still in play. I called a local Center of Excellence and they told me the 18 month requirement was still in play. I asked if there was any way around it, to which the girl respond…

does anyone know if kaiser northern california is starting to do lapbands? i know they do the roux en y but i feel more comfortable with the lapband. thanks for any info.

Everything has been submited to Cigna. I am so scared it not going to get approved. I have done all there requirments but let face it It Cigna I am dealing with. So wish me luck because I think I am going to need it.

I STAY IN SOUTHERN IL AND I HAVE A STATE MEDICAL CARD(MEDICAID) I HAVE HEARD THAT IT MAY BE SOMEBADY WHO CAN GET LAPBAND ON THE CARD BUT DON'T KNOW WHO NOR WHAT YOU HAVE TO DO FOR APPROVAL. LOOKING INFORMATION:sad:

Do anyone know if your claim is denied by BCBS FEB because one of their criteria is not met (6mon supervised diet), can it be submitted to your secondary insurance for approval for lap band surgery? Secondary is Tricare prime. Any chance for approval doing this?

The one question I have is about my insurance I have Horizon BCBS of NJ. I wanted to meet with a few Dr.'s before making my choice on a Dr. Two of the dr. I have went to say I need to pay them 1700.00 or 1800.00 up front for the nutritionist and physiological part for me to get my surgery. This last one I went to says my insurance co will not pay for a surgical assistant so I will have to pay them 500.00 ontop of the 1700.00. Then the nutritionist that I have seen only once is the Dr.s Niece. They don't seem very professional at all. I called my insurance co and they didn't know what they were talking about when they said surgical assistant. Has anyone ever heard of ha…

I have highmark bcbs and my ins received my info on 7/7/08. The precert said they would return a reply within 15 days. Today is the 18th of July and they contacted my surgeon re: the docs name at the wt loss clinic so I gave that info to them. This ins has a 6mo wt loss cumulative within 2 years of the request. I have wt watchers, curves, LA wt loss, Ageless WT loss center- the physician they asked for, Total Med-I saw a nurse practitioner and she prescribed meds. I have 10 months worth and my PCP referral letter stating recommend lapband d/t comorbidity of high lipids joint problems. My BMI is 39. I am hoping this doesn't mean they are going to try and deny me…

My husbands company may very likely be switching from Cigna to an inferior company...needless to say they do not cover baraitric surgery. Cigna does and has been just wonderful this far. I am not due to submit my paperwork until the end of November (END OF 6 MONTH DIET) and we switch over Jan 1st....It is VERY likely that they may not make a decision until after Jan...anyway now I am looking into cobra....I would have the same coverage, and I would only sign up myself...the rest of the family would go with the new insurance....has anyone had to switch to cobra during this process, or had to go from Cigna to Cigna cobra??? Thanks for any insight you may have. Kimb…

I started my 6mos wls diet with my doctor in March. I went every month until June and then made a decision that I wanted to try and lose it myself rather than surgery and stopped going to the Dr. However, I got a personal trainer in June and he asked me all about my diet plans and documented my weight and diet program. Then I started going to weight watchers in July, and I know insurance companies now accept weight watchers meetings. So basically I have all 6 months of my weight documented and what diet program I followed. I have lost 32 pounds but I know that I need the band to help me continue my weight loss, and to finally maintain it for the rest of my life. I have …

I have BCBS of Florida PPO. I am not sure whether or not the surgery is covered. What will they be looking for? Attempts to loose weight? I recently didn't do well on the Metabolic Research Program, did ok on Weight watchers? Problem, I am just getting bigger and bigger and it's in my genes. Do they look at diseases like Hypertension and High Cholesterol which I have already. Diabetes is rampant in my family but, I have not been diagnosed with that.

Hi! I have some questions about BCBS of TN. First, has anyone successfully gotten WLS procedures approved through BCBS of TN? Can anyone provide any more information about the 'hoops' they had to jump through to do so? My doctor suggested trying WLS a couple of years ago, but I kind of just shrugged it off thinking that I could do it myself. I don't think I can. I've tried and I'm turning 27 this year and I want to have kids in a couple of years. I know that I won't be able to have kids like this. I don't want to live my life like this anymore. I haven't been happy for a long time and watching people be so successful with WLS and other methods just really makes me…

Hello all I am new to this site and I was wondering what my chances are for approval. I am in the beginning stage of of doing my test and am firm on my decision to want to do the lap band. Currently I weight 320 I am 5 11 with severe sleep apnea, high blood pressure and starting to have joint pain. I have tired to loose weight but cant keep it off or loose enough. I have been with my primary care doctor for 2 years and another doctor for 3 years but i always been heavy would I have to get records from both? Anyway any help would be greatly appreciated I have blue-cross blue shield of Tennessee.

My ins. co received paperwork on 7/7/08. On 7/23/08 my surgeon contacted me and told me that the ins co said they could not use the first MDs note because it was over 2 yrs old. 6/26/06, or were I saw the counselors there after for the month for my diet counseling wt in etc. I would like to know what all do u have to have for the ins? My ins is BCBS PPO Highmark, they say at least 6mo supervised WL diet for a cumulative of at least 6mo over the 2 yrs prior to surgery. I had a copy of my ins policy and it says that it takes physician supervised or counselors, exercise that is working under the MD supervision. They would not count the mo of LA wt loss or weight …

So....I heard from my surgeon's office today, who talked to BCBSIL today. They said I need to fulfill my 6 months supervised weight loss program, which is ONE more visit with my Primary Care Dr. SO....not the news I had hoped for, but the second best news for sure. They could have just flat out denied me. I was hoping they would count my Weigh****chers, but they said it had to be DR supervised, which was not a surprise either. It seems as if they are going to take 6 visits rather than 6 full months (180 days), so that is great news, hopefully they will follow through with that anyway. So I have an appointment with my physician on Sept 2 and then hopefully we will get t…

Hello All, Does anyone have BC/BS in Southern California that has gone through the Insurance song and dance and has been successful getting approved. I had tried last year when my company went from Preudential to BC/BS and I chose an EPO plan. When I tried applying for the surgery through several doctors I was denied becasue they said that the EPO I was under didn't cover it. So I had to wait a year when I can change my plan to a PPO to re-apply. But I'm worried that I will still have the same problem so I wanted to know if anyone out there has had any sucess and can give me some suggestions. Wish me luck. I need it to save my own ife. Thanks

I received my surgery date at the end of July and I was told my paperwork would be submitted to Cigna right away since they tend to be rather slow in making decisions. A week after I met with the coordinator, I e mailed her to see if she had submitted my paperwork....she had not but said she would do it last week. E mailed today to see if it had been done, of course not. I am worried she is going to run it right up to the line and I will not get approved in time. My mother is flying in to take care of me after surgery and I am gonna be mega pissed if I dont get approval in time due to this. I am trying not to be a pushy b****, but its getting hard for me. Any sugges…

So after reading here that Tricare required an overnight stay I asked my Dr. office to look into it. She just wrote me back and said that Tricare did not require an overnight stay. I have Tricare Prime (Humana South). Just want to be absolutely sure this is correct. I certainly cannot afford to pay for this surgery because someone made a mistake. So, overnight stay required or not?

I was finally submitted to Insurance Today. I am praying that it does not take to long to get approval.. I have heard some people are approved in 1 day and others in 30 hope mine is closer to the 1 day mark :biggrin: In January I decided I wanted the surgery and was unable to attend the seminar until March. I then started my 3 month Diet and thought I would be submitted once I was done with the Diet at the end of June, but instead it took my Dr. office a month to get my Records together.. Now I hope that I don't have to wait another month to hear back from Aetna.. If anyone has any advice on how they handled the wait I would love to hear from you

Hello all I have just filled out initial paperwork for the lapband surgery. I was weighed, and had my height measured at a Center for Excellence Hospital in El Paso, TX. I was told that my medical records would be requested from my doctor, then the surgeon would write a Letter of Medical Necessity to my insurance company, Blue Cross Blue Shield of New Jersey (I know what youre probably thinking, what is a girl in Texas doing with BCBS of Jersey, but my company has many offices around the country, and everyone gets the same insurance). After that, there would be consultations with various health care professionals, and there would be a whole lotta testin' going on. …

I am in the process of getting approval from BCBSIL...I have only seen old threads from March of this year and a lot from last year, that BCBSIL was not good on getting approvals, I was hoping to see them approving banders in 2008...BCBSIL is well known for not approving the lapband surgery...I am getting upset over hearing this bad news... Can anyone give any good news about getting approved by BCBSIL:confused2::confused2::confused2:???????

I was approved and banned last Tuesday (August 5th) and I have Cigna insurance. What kind of bill should I expect to see? Did you just have to pay for an emergency room visit or did they hit you with all kinds of non-sence charges like emergency room tech, and 1 injection needle and 1 face mask etc. Like how much did you have to pay when it was all said and done. Did they bill you or did you have to pay up front?

APPROVED!!!! I'm so excited!! I have my physch eval tomorrow and hopefully will be scheduling my surgery then. I was really worried that I wouldn't get approved because I'm not 100 lbs over the metlife recommended weight scale. But I have a lot of comorbids. So I guess that was enough to put me in the approved category!! In my family there is a history of death from strokes, diabetes and heart disease. I'm 35 and mother of 4 kids that are under 6. I want to be there for my kids and husband. I haven't told my husband yet, because he would never go for this surgery. So I still don't know what to do about that!?!?! Guess i need to get me a weightloss tracker on m…

My PCM showed me a paper today with the list of requirements because she wanted to be sure she gave me all the referrals I needed (love that woman). One of the things listed was a PU_ test (as in PS-something, all initials) and she and I weren't sure what that was. Anyone know? I have a phych referral and a nutritionist referral...will I need any other referrals? This is getting overwhelming.

So Day One Health Chicago just submitted my paperwork to bcbsil. I am such an impatient person I want an answer now! How long did it take for your insurance companies to approve or deny your claim? Pray for me please!

I was told by Regence, my primary insurance co. that my plan does not pay for this type of surgery but I called back and was told I could appeal. I'm also covered under my husband's First Choice/Unicare and I understand they do cover this but I'm not sure how much and what they require. Does anyone have experience with these two companies? Kat

:confused:Is it easy to get approved for surgery by Tricare once you have your Pcm's referral in process??? I am 220 lbs 5'5 and I will be meeting with my surgeon at the MTF for a full exam at the end of the month. I'm just crossing my fingers and really hoping Tricare will approve me for surgery...I have never been this anxious or nervous about anything in my life...Well if anyone can help or has gotten smooth approval please share your expeirence...Thanks!

Hi, After reading for days, I think I've pretty much decided on Dr. Ortiz in Mexico. I've received what I feel is an amazing price compared to the U.S. My doctor here quoted me $15,000 cash pay and fills aren't included. Anyway, my question is this......Can anyone tell me the best company to use for financing this procedure? I've been give a bunch of brochures about different companies, but would love some first hand information. Thanks in advance for your help! :cry_smile:

I went and saw my PCM a couple of weeks ago for my yearly pap and asked her about banding. She said she would research the requirements and if I was really interested, she would put my referral in. She called back later in the week and said that I fit the criteria, so she would put my referral in. She put it in for Bethesda and it got kicked back because Bethesda doesn't do WLS, so she put it in for Walter Reed. I went out of town for 3 days, got back today and had my referal letter in the mail for a civilian doctor in town, which is fine. :tt2: But, um, what now? :confused2: Do I just call up and say, "Hi Dr so-and-so, I go referred to you by my insurance company for gas…

HELP !!! My doctor is unsure of all that he needs to cover in the letter to my insurance company in order to get me approved. He says he is even willing to state that I did a 6mth program, even though I didn't!!!! :tt2::smile2:He is so sure this is exaclty what i need in order to get my health back. He isn't sure what is needed in writing to back up his statements, and wanted me to get some insight on this.

Has anyone had any dealings with American Heritage??? It is apparently a subdivision of Allstate. I would appreciate any insight. Kimberly