Insurance & Financing

I just got a call from my case manager at Triwest. I am approved! Next step is to connect with the surgeon's office, which should be a little easier now that I just need to make an appt for a pre-op, instead of trying to talk specifically to the insurance coordinator. I was told at my initial consult that surgery is usually within two weeks of that, but there have been vacations for the doctor in June, so she may be scheduled farther out. This has been an emotional roller coaster for me, from the day I first found out that Tricare would cover a lapband! Right now, my hands are shaking. I don't think I have any unrealistic expectations. I'm anxious, and eager to…

I just got the call from the Bariatric Center and she said they sent the info to bcbs of MN last night. So I called blue cross and they said they dont see it yet but thats normal and I should wait a few days. I am sooooo nervous. I cant sleep and I eat more because I am stressed out!!! I have all my plans though if I am denied my doctor will do a Peer to Peer first.. And just to let yall know this is what anyone should do before the appeal my doctor said she had only been denied the peer to peer once since she has been doing them. So if I am denied with the peer to peer I already emailed the obesitylaw.com for the appeal so I am just waiting sick with a headach and no sl…

Hi Everyone, I'm new to posting but I've been lurking and learning for awhile. I went for my first appointment yesterday and I'm really excited. Everything looks like it will be fine for my insurance and I know Oxford is pretty good about approving people, my only concern is documentation of weight for the last five years. Has anyone else provided this? They don't need to see a diet or anything like that, I just have to prove five years of obesity. This should be easy, but I'm concerned because between two and three years ago I wasn't going to the doctor regularly at all. If I went five years ago, then maybe a year later, and then a year and a half ago, does that see…

There is a man outside apraising my house. Trying to get the money for surgery and that means refinancing my home. I am self pay and because i have sucky insurance that has a clause a no weight loss surgery! :thumbup: But I so desperately want it and need the money soon. I have my appointments set for all my consult. They called yesterday and i now have an appointment for my ugi and h pylori test. July 21 and I feel once i have the money my surgery will be set. So need some reassurance and prayers that i will get the money I need and that It will be worth it. Plus right now paying out of my own pocket ouch! So anyway I just am desperate and scared. My family is supportive…

Does anyone here know if Humana pays for fills after the surgery? cheryl

As with most self-pay lapbands, the 1st year of fills are included with the cost of my surgery. I'm thinking ahead to year 2, and I'm wondering - are fills an FSA eligible expense? If yes, is any documentation required? Thank you in advance.

Just wondering if anyone out there has MAMSI / Optimum Choice and if so, how easy was it to get approval? I spoke to them and it is a covered procedure if you follow the steps but I am still concerned............I am so motivated to do this I am afraid something will go wrong ;(

Hello I am finally approved right. So I think I am good to go and will get the letter within a week. I was approved June 9th. Never received a letter. Got one from my Dr.'s office saying congratulations on your approval so I thought ok Aetna sent them a letter and not me no biggie right? Wrong! I get a call from the nurse at my Dr.'s office saying 20 days later Aetna never sent a letter and they can procede with surgery without that. After I have already scheduled surgery which is on the 15th I had just did my Upper Gi the day before and was scheduled to see the suregon on Mon. and blood tests today Wednesday. So my question to everyone is I called Aetna three times on Fr…

I thought that my PCP would submit the initial paperwork, but from what I'm reading, so people meet with the surgeon first. Who submits the initial paperwork to the insurance company, one's PCP or surgeon? If the surgeon submits it, does insurance pay for the consult with the surgeon? I have UHC. Thanks in advance

So I finally got an appt with my PCM today and after much arguing (she had old info, that i had to go to a MTF, needed a specific BMI and 2 comorbidities, etc.) she put in a referral for me. Where do we go from here? I'm in MS if that matters. Thanks in advance.

My insurance says they only cover $7,500, and the first office I called said it would be CHEAPER to go self-pay cause they charge the insurance company twice as much than their self-pay rate. Anyone have this cap on their insurance, and how much did you have left over to pay?

I finally got my approval letter today from Horizon BC/BS of NJ after six months of dieting "again" I've only been doing this for 15 years actively, but not under my doctors strict supervision. I completed the six month supervised weightloss program and have been approved and have a surgical date of July 29th. I can't wait. My surgeon is Dr Bertha from Florham Park has anyone else had him? I've met him several time and like his manner, and approach.:tt2:

I just looked at my referral for tricare online and my status is 'pended'. Does anyone know what that means? Seen it before? Is it good or bad? If you were pended...where you approved or denied? so many questions!! ahahahahaha...what an agonizing process!!:confused2::frown:

Hi ladies. I need Help!!! Im in Germany.. If any on you are, who did you see? Dr. Weiner in frankfurt? Im really nervous about what to tell the dr and the whole procedure. I know you have probably told your story 100 times but i would love to know you experience with Tricare. Im going to the clinic on base on teh 15 of july. Im guessing he will give me a referral to the weight loss dr in town???? Can you primary doctor say no to even giving you a referral? I was told i would have to get a psych eval, sounded like that would have to be done and cleared before i could get the referral. Did you have that problem? What is critical that i tell the doctor at the…

The only dr I could find from the last 2 years was 18 months ago and he did not write down the weight the first time I visited him (even though we talked about it) and the second time he wrote "250+! Weight needs to go down!" I was 256 or so the first time I saw him, exactly 40%. Second time, I guess 254 or so. Grrrr. How can the ins companies expect me to get a good record if #1 I hate going to the dr because he weighs me (I had hurt my foot) and #2 if the dr doesn't keep good records!

Hello all, First let me say this board has been a God send and so comforting to hear from folks on the same journey. Not sure if anyone can help with this one. I currently have 2 forms of insurance: Cigna Open Access (primary) and Tricare Prime (secondary). Cigna wants the 6 month diet, 5 years of documented weight, psych and nutritionist eval. Tricare on the other hand only wants a BMI over 40...which I have. Here's my question...if Cigna denies me, will Tricare automatically cover me? The WLS can only tell me that if Cigna denies me, we'll have to "start all over." Huh? Anyone with a similar co-insurance experience. Thanks! ML in VA:confused_smile:

OK so I did all I am supposed to do. I have my 6month diet also 5 months with a nutrtionist. I did the sleep apt study. I did the phyc eval. I did everything I had to do. So its time to file on the 23rd (my patient advocate is out until then) and I was reading over the requirements for bcbs of MN and it says 2 year weight history. Hmmm why didnt my patient advocate mention this as a big deal? So I call bcbs of MN and they say oh yea that will be a problem if you dont have a weight history. So now I am freaked!!!! I found one doctor apt and guess what I was on a diet at the time and my BMI is 36. Right now my BMI is 41 with no co morbities. I am so scared I will be denied.…

My INS policy has a weight loss exclusion... I am 31... and im 5'5 , 250 with sleep apnea and gerd... I have an appt with the DR i want to do my surgery on wednesday and i have gotten 2 calls from his office since i made the appt to let me know that i have an weightloss exclusion... which i already know! But they are making it seem like i have no chance to win if i appeal it... I plan on getting it done no matter if i win or not... i will finance it... but they are making me feel like fighting it is a waste of time?? Help!!

Does anyone know about the approval time for this insurance? It was submitted last Thursday (they might not even receive it until today because of Good Friday). I am not expecting to hear anything this week (but still biting my nails waiting!!). Also, I have diabetes and sleep apnea (severe). Does this usually help to get approval???? Thanks!! Ready to get started in CT!!!:wub:

I have a few questions. I am halfway through my 6 month supervised diet, and my workplace is changing insurance as of July 1. I have already spoken with the new insurance company, they cover lap-band, with qualifiers. I have no "qualifying" co-morbidities, that is why I want the surgery to prevent myself from getting any. My parents have just about every illness and I want to be a better role model for my young daughter. My BMI must be over 40. At this exact moment, I am 39, but 5-6 months ago I was over 40. I am wondering if I have to be over 40 at the time they submit to insurance. Thanks for any input.

I have blue cross/shield of Alabama. I had an appointment to go see doctors at UAB about just self paying for the lap band. Found out the day before my appointment that I was pregnant with my second child. I'm excited but a little disapointed about my lap band plans. My question is, has anyone ever had success getting coverage if lap band surgery is mixed with another surgery - like having tubes tied? Or, do you know if self pay would be cheaper if combined this way. I may be reaching, but thought it was worth asking. Thanks, Amy

Does anyone have BCBS of Michigan? How long did it take you to get approved?

I was wondering if anyones surgeons required the 6-month diet. . .or if that was an insurance company requirement?

:bananapartyhat: :bananapartyhat: :bananapartyhat: :bananapartyhat: :bananapartyhat: :bananapartyhat: :bananapartyhat: :bananapartyhat: :bananapartyhat: :bananapartyhat: :mad: :mad: :mad: :mad: :mad: :mad: :mad: :mad: :mad: :mad: Do not get your hopes up if you approval for office visits from Tricare. Everything will go fine until you need final approval for the actual surgery, then they will deny you. I was one week out from having surgery back in June and the Drs office called saying they have not gotten approval for the surgery--you do all the work call Tricare have the insurance person at the drs office work with you and then they deny at the last minute. I was Tri…

Hi all! I've been a lurker for awhile and have been browsing this forum. I meet the criteria for lap band, but my company has an exclusion for WLS under BCBS in Georgia. I've seen several people who have won appeals, and I need to know whether you can appeal an exclusion or if the appeal was just because the insurance companies covered WLS but didn't want to approve it right away for whatever reason. I'm a little confused on the formalities. I really can't afford to pay out of pocket, but I think there may be a chance for my insurance to cover it from what I've read here. I would appreciate any help so much!

I work for the board of education and have bc/bc of al peehip. How hard is it to get approved? Does it take a long time to get approval? I,m just starting out and talking to the ins. company is like talking to a tree. They never answer a question fully. I really don't know what to expect. Any info would be great. Thanks!!

I'm a little confused....my Aetna plan covers Lap Band, no problem...they also cover RNY, but not both on the same patient. Obviously, I've decided to go with Lap Band...my confusion is this... Aetna will only cover ONE WLS surgery the life of the plan, no problem there...I understand that. However, today when I was speaking to a rep from Aetna I asked, "what if my band goes bad, or something happens to it? Will you guys pay to fix it?". Her answer was, that they will pay for any medical complications that arise from the WLS I choose. I'm confused....if my band goes bad, or if my port flips or, I spring a leak...are they going to pay for fixing/possibly replacing my b…

Hello. I'm in PA and have Highmark PPO Blue Insurance. My BMI is 37.2 which puts me in the less than 40 but greater than 35 class. I have Arthritis in both knees and lower back. I wear a brace on one knee. I also have Acid Reflux and high Cholesterol. I am two month's into my six month supervised diet and my surgeon told me I am borderline at best for approval. The insurance girl in the office told me if I meet the requirements I should be in very good shape for approval. I hope she is right. Has anyone else out the used Highmark Blue PPO and what were your results?

Has anyone ever had this happen? I was approved for surgery; my surgeon is in network, etc. My surgery was last March. BCBS paid for the hospital, the anesthesiologist, and the upper GI. I spoke with BCBS every step of the way to make sure of coverage. I recently received a statement from BCBS saying that my surgeon is not covered. How could this be? I am so confused.:confused2: Thanks.

Hi everyone! I sent my application to the Southwest Medical Center in Vancouver, Wa last week. Am I suppose to call the insurance company myself to see if I am approved or do I wait for the doctor's office to call me? I am not sure how the process works. Thanks! Michelle

I called my insurance co. and they told me they approved the Lapband but when I went to the surgeon's office they said my insurance company has a stipulation that I be on a medically supervised weight control program for 6 months. I've been going to Weight Watchers for almost that long. Shouldn't that count? Does anybody know of a way to get around that? It took me long enough to decide to get the surgery to begin with! HELP!!!:cursing:

Really quick... Does insurance usually pay for the psych eval if you already have insurance coverage for psychology/psychiatry? Does insurance pay for the other pre op appointments you're required to attend? How does post op work? When you pay the $15-20K (or insurance pays there part, you pay yours, or if financing is used... either way).... is followup included in that amount? If you're using the same doc to do surgery and fills. I'm just trying to prepare myself for any extra expenses I might incurr.

Hi everyone, I'm new to the forum and had some questions I'm hoping some of you might answer. I have Aetna PPO. I've read the clinical bulletin regarding coverage of bariatric surgery. I understand that I need to have a BMI of >= 35 and either 6 months of a physician supervised weight loss program or 3 months of multidiscplinary team weight loss program. Right now, my BMI is just over 35, but I have several co-morbid conditions (diabetes, sleep apnea, hypertension, high cholesterol). If I go on a weight loss program and my BMI drops below 35, will Aetna deny the procedure? I'd appreciate any assistance. Thanks so much! Jen

I have had it! My dr. submitted everything on 6/5 and hasn't heard back yet. I called UHC to check on the status and they are telling me (again)it was approved by in April! Did I or the dr get a letter? NO! Nothing! They said the inital clenical info given in April were all that were needed, no psych eval, no nutritionist, nothing! So, this could have been scheduled and already done by now! AGGGH!!!

My insurance won't pay for the Psych Evaluation and I'm trying to find out what a reasonable cost is. The clinic I'm using recommended a Psycologist and after I made the appointment found out it wasn't a covered expense. The cost is $1,200.00 from her. I don't know if they inflate the price when Insurance pays for it or if they are all this high. Does anyone know if there are different levels of evaluation for different prices. I certainly don't think I need the full blown, on the couch treatment.

I have only been on this site for a few days and I have Aetna PPO Choice. I have read MANY times that Aetna required a 3 month diet and I did not need to do that for approval. What is the purpose of the diet and why do they require it for some in order to get approved? Just curious:confused:

I am wondering if anyone out there has an EOB showing the amount the insurance company paid to the hospital. (amount allowed is what it is called on the EOB) I paid cash and am trying to submit a claim to my insurance company for review, but I am wondering if it is even worth it to do so. Thanks! Donna

I have a friend who is a nurse at our local hospital. Her insurance is called Health Future. Has anyone heard of this company? Does anyone know what this insurance company requires to be approved for surgery?

Okay my surgeons office sent in my paper work for insurance approval. So i called my insurance company, BCBS of MICHIGIAN, last friday & asked them have they received my information & they said they received it on 5/13 & it is still being reviewed. Now i understand they don't do a pre-approval, so what will they do:confused:. I am so ready to get this show on the road before the long summer hot months come. I have not even got a date yet. I guess the surgeon is waiting for approval also. I have been through everthing but i have to retake the breath tec test on this friday. I hope i pass it this time. Anyways i saw one of the girls that works where i do that w…

Hello All! I am a self-pay potential lap-bander. We tried to refinance our home, didn't work out. Now I am looking at a personal loan through a credit card. It would be approximately $330/month for 60 months. Is it worth it? I am telling my husband that it is similar to a car payment. I am willing to drive my chevy until the wheels fall off to pay for this procedure. Any words of persuasion to tell my husband would be much appreciated! Thanks, Angie

Does anyone know if Kaiser SD is doing the lap band surgery ? if so what is the process?:redface:

I'm in Nebraska and have Midlands Choice has anyone else been approved by this company, or know of someone that was approved?

I was researching diabetes (dad with type 2 diabetes and I'm experiencing same symptoms) when I stumbled on information concerning the LapBand procedure. I have struggled with my weight since my first baby was born 10 years ago. I have a family history of obesity and have fought my entire life, so tired of being hungry. Very much a lifetime yo-yo dieter. I am at my current highest weight. The LapBand is only something I am thinking about doing at this point but from what I have read I feel this is a lifetime solution to my obesity issues however will not consider unless insurance will cover. If anyone has any insight to my situation please let me know. I have Blue Cross…

I was approved this morning by Tricare for surgery. Now I just need to get my date. I think I will have to call them to change the valid through date though. They have it valid through the end of this week, the 27th. I have to pick my daughter up from the airport on Friday, so unless they do it this morning, I just don't see it happening this week! It took longer for my surgeon's insurance office to send it in to get approved then it took for my insurance to approve it. They had everything they needed to send it in 13 days ago, yet it went in this morning!

I have a tentative date for 9/3/08. I am waiting on insurance approval, and my stomach is doing flips. Quite nervous about getting approved. Completed required test, eval, and consults. Did not loose too much weight during 6 mo nutrition plan. Although, was instructed not to do so. Have Connecticare? Has anyone had any problems with them?

Anybody have to deal with Qualcare insurance? They told me that they cover 100% but only if deemed medically necessary. Just wondering how tough they are on that. :confused2:

Anthem BC/BS paid for the surgery but they are not paying for any of the post-surgery visits; not for fills, checkups, anything. When I call they just say they are not a covered benefit - WHAT? Anyone have the same issues? What did you do?:smile:

I have Definity/UHC and had my consultation with the weight loss center last week. Have a bmi of 40.2 which should qualify me with no co-morbidities. When I called Definity they said I would need a psych, nutrition and excercise consultation. Just wondering if I should pay for these now or wait until my paperwork is submitted first? Will they approve pending these reports or want them before hand? Thanks!

Hi! I was approved by Aetna! Surgeon's office submitted on Thursday morning. Aetna told surgeon's office they authorized today. That seems fast to me! I did the 3 month multidisciplinary diet. I paid the fee to Dr. Cirangle ( huge fee that hopefully gets mostly reinbursed by Aetna) and then am waiting to schedule the surgery today or tomorrow. I am hoping to schedule it for the week of July 21st. That would give me a month to recover before going back to school( teacher). I leave for Mexico next week for a weeks vacation and then will have to do preop testing etc... Anne

Hello everybody, I just can't believe it I am almost there! I received the most awaited phone call in the last 2 weeks. They told me I was approved and scheduled for surgery on May 27. I just want to give some words of encouragement, I am a low BMI (35.7) with PCOS, Infertility, Hypothyroidism, sleep Apnea and begining stages of Diabetes II. So I have the comorbidities, but still low BMI, so there is hope out there. Insurance companies seem to be approving faster now, I think because they see that with the lap band is one time investment in your health and form that point you will be healthy....Treatment of the Diabetes is very expensive and infertility just to men…