Insurance & Financing

Title: Surgery for Morbid Obesity Number: SUR716.003 Effective Date: 07-01-2007 Legislation: ILLINOIS: None NEW Mexico: None OKLAHOMA: None TEXAS: None FEDERAL (applies to all Plans): Contract: Each benefit plan or contract defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers have the responsibility for consulting the member's benefit plan or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan or contract, the benefit pla…

I found an attorney who says he thinks he can help me through the appeals process, but I am hesitant. Has anyone had any luck with the help of an attorney, and if so, who??? Thanks...

or BMI of 40 or more? Does that sound right? I took notes when I was on the phone with my insurance co. and it seems that if my BMI was at least 40 I did not need any comorbidities. Does that sound right to any of you?

Hello everyone. I have finally made up my mind to do this and found out my insurance will no longer cover lap bands after December 31st. I have attended the seminar, my pcp is in the process of finishing my letters of neccessity and clearance. I have a appointment to meet the surgeon and physchologist in the next month. My question is how long is the wait time and is is possible to have the surgery before December 31st? Any info will be greatly appreciated. :cry

Hi there. I have been lurking on this section because my employer is shopping for insurance companies and may possibly go with BC/BS. I'm in AZ. I see a lot of people posting about different states, so I was wondering how it varies from state to state? Why can't things just be simple and have freaking health care across the board?!?

I was wondering how long others had to wait recently for Anthem BCBS to authorize for this surgery? I've done everything they said I needed to do and fit the requirements. My PPO referred me and I saw the lapband surgeon, went to the dietician and psych eval, etc. I'm now waiting for authorization before I can proceed to finalize this and set a surgery date. I've been waiting on insurance to authorize this for a month. Is it normal for it to take this long? My Lapband doctor (Dr. Keith of Norman Oklahoma Weight Loss Options) said I should hear back in a week or two but it's been a month now. I tried calling them early last week but the insurance lady wasn't there…

My BMI is 39. If I want to have Cigna cover the lap-band I need 6 months of supervised diet and exercise. Well of course I can probably take off 10lbs, (it's keeping it off that has been a life long struggle) but then I'll have lost some of the BMI - making me less of an "appropriate" candidate for coverage. You need to have a BMI of 40 to qualify. Or, do I just suck it up and self-pay, assuming I may have to pay anyway even after the supervised diet? Any advise or suggestions? edited to add: I have no co-morbidities and am very healthy.

Hi folks: hope you're doing well for this holiday weekend. I wanted to remind all you potential LAP-BAND folks having (or expecting) trouble from your payer that there is a FREE APPEALS PROGRAM available to you if you have been denied your LAP-BAND and as you get closer to the end of the year, when insurance changes for many of us, you could possibly be making a big mistake by not being more aggressive in fighting your insurance company now - especially those of you who are in the process of trying to do their six or 12 month "supervised diet." Remember that if your insurance changes to an exclusion or coverage is somehow limited while you are in the middle of this "su…

I can't believe I'm typing this -- I'VE BEEN APPROVED!! I've been on this roller coaster ride for so long I'm still in shock that I will actually have the Lap Band! I'm just so excited!!

I have a BMI of 48. Was told on the phone that they would cover procedure if BMI was over 40. I also was told they only approve after you have all of the surgeons requirements are satified. So that leave me feel vernalble to having to self pay for all of the appointment I already have gone to if I get denied. Is therer snyone else out there who has had the surgery and federal BC/BS paided. Worried in Western Mass. Peggy

The doctor I was planning to use and saw for consult and who just filed for surgery approval isn't on my preferred provider Aetna PPO plan anymore! They were 8 months ago but no longer. Only when I emailed to ask was this revealed!! So now, if approved I will have to pay for over 50% out of pocket or find another Doctor who is on the Aetna IN-NETWORK preferred provider list. I called Aetna to ask for a list of names and they were NOT helpful. Told me doctors prefer to not be labeled with that title (lap band surgeon) and suggested I do my own research. HUH!?!?!?! Anyone here know of a good caring Lap Band doctor in the Houston/Beaumont/Galveston/southeast texas area th…

Has anyone experienced their insurance to approve them but as an out patient? I was and am one week post surgery. I would love to hear others experiences.

Hi all! I've recently gone to my first consultation with my PCP about the band and she's behind me all the way. She wrote me a referral to the nutritionist that I need to call on again (I called before to ask if there was a charge and I got voicemail and never got a call back) and wants me to do a few months sup. diet before trying for a referral to the surgeon. My insurance sucks and will put up a big fight, I know this. I talked to another lady at the info session who has my same insurance and said you have to do 6 months diet first, then pursue an appt. with the surgeon, and they'll only cover it if it's life-threatening. Ok, so I know where I stand with insurance. …

Does anyone have any experience with Preferred Health Plan? After two denials by BCBS of IL, I ended up getting a new job and put the whole thing on hold while I moved to MD. My new provider is Preferred Health Plan, and I'm just starting the process anew. My new doctor will let me know what the insurance requirements are, but I thought I'd ask and see if anyone else has any experience with this plan administrator.

I am interested in knowing when a person self pays what the insurances obligations are if complications arise. I just was reading some of the slipage, reflux, etc. complications and it concerns me for the future if I self pay.

Here is a change to the Tricare manual which has yet to be added to the manual and few seem to know about if you call them. CHANGE 55 6010.54-M JANUARY 30, 2007 SUMMARY OF CHANGES (Continued) CHAPTER 4 (Continued) 5. Section 13.2 (Surgery For Morbid Obesity). 43644, 43842, 43846, and 43848. No change. New CPT procedure codes were within procedure code range. We added the following to Exclusions: laparoscopy, gastric restrictive procedure (CPT procedure codes 43770 - 43774) and gastric restrictive procedure (CPT procedure codes 43886 - 43888) is unproven. Added “for gastric bypass procedures” for unlisted codes. 6. Section 20.1 (Nervous System). 61000 - 6…

I was wondering, if insurance paid for your band do they pay for the fills? Thanks

Just got phone with them again to ask about the lap band.I absolutly have no coverage.I have Optiam Health thru work.Boss would have to add to his policy.This just really sucks.Just pisses me off.

i think my insurance is called Mutual Assurance Administrators but then my card also says "First Health" on it... i work for a police dept. so I also have paperwork that says Oklahoma Municipal Assurance Group. does anyone know who my insurance company is?! lol this is nuts... *sigh* i read further on in the novel that I was provided with when i was hired and there's a page that says "Procedure for appeal of denied claim" this paper says that if i were to be denied and did an appeal i would mail the appeal to the Mutual Assurance Administrators. so does that mean that my company is MAA?

Hi everyone : ) I just wanted to tell everyone not to give up your dream of being banded . I also want to say that make sure your medical records have your correct height. It sounds silly but this is very important. Those few inches make a big difference in your weight and BMI (make sure your shoes are off). My family doctor had me recorded at 5 feet 7 . I turned in my information to my banding doctor and recieved a letter back saying I do not meet the qualifactions for being banded (through insurance). I went to see my lapband doctor about self pay and he told me I don't look 5'7" and I took my shoes off and stood naturally and I was 5'4". Those 3 inches were enough t…

I want to know if i should keep tryin or give up. My insurance states exactly this. Medical and surgical services, initial and repeat, intended for the treatment or control of obesity, including clinically severe (morbid) obesity, including: Medical and surgical services to alter appearances or physical changes that are the result of any surgery performed for the management of obesity o rclinically severe (morbid) obesity; and weight loss programs or treatments, whether prescribed or recommended by physician or under medical supervision. I just dont know if i can get around that wording.

CNN REPORTS THE MOST COMPREHENSIVE PROOF THAT Gastric Bypass Lowers Risk of Death TIME MAGAZINE AUGUST 22, 2007 By Sora Song Whether one regards bariatric surgery — last-resort weight-loss operations such as gastric bypass and stomach stapling — as an essential treatment for obesity or as a failure of the fat person's will, the fact is, it works. Studies have shown that after surgery, patients often lose 50% or more of their excess weight — and keep it off — and symptoms of obesity-related conditions like diabetes, high blood pressure, high cholesterol and sleep apnea are improved or eliminated altogether. Now, two new studies in the New England Journal of Medic…

Does anyone have family health plus and has gotten the surgery? Please let me know if they cover the surgery or not.

Does anyone have a lower bmi of 35-37 with borderline comorbidities and were approved or denied by BCBS Texas? I am so worried that I won't be approved.:help:

Hello I was wondering if anyone with UHC has ever gotten thru a policy exclusion for any weight lost surgery. I am sure I can show need, I am 6'4" and over 450 lbs, my BMI is over 54, I have borderline High Blood pressure, a family history of diabetis and heart problems., and an artificial hip. Tony

Hi Everyone, I've just read the Aetna threads. Aetna Choice POS II is my plan. Is there anyone out there who has this plan or a similiar one? I would love any feedback, suggestions, and/or helpful strategies in dealing with them. So far, I've learned that my plan covers only 90% of the surgery. I'm not sure about fills. Again, all info is greatly appreciated. Soon To Be, Skinny Chick:)

Hi, all you friendly and helpful folks - I need your help. I've heard from some sources that Aetna requires documentation from a physician of each of the past five years of obesity, and from others that they didn't need this. (I don't have that documentation, though I've been obese for over 20 years.) Is this going to stop me from getting coverage? Also, I've now heard that a bunch of people have gotten approval using the 3-month multidisciplinary diet/exercise program. For anyone who has: did you need documentation from an exercise specialist, nutritionist, PCP, and mental health person? Or just the last three? And if I've been seeing a therapist for years but…

Hi Everyone! Has anyone with BCBS and a BMI of 35-40 had the surgery approved if you have a comorbitys like asthma and Gerd not necessarly the ones that are listed on their list....I was wonder because they say "such as" in the writing making me think that those are examples of ones they cover not ALL of them....Thanks for Any Info!!! ~Xgrl

Hi Everyone, I am doing a little research before I submit my paperwork. Is it better to send all information upfront (i.e. physician letter, medical records, documentation, etc) or should I send a physician summary letter first and then submit the rest of the info if asked? By the way, my insurance carrier is Aetna, my plan is Aetna Choice POS II. Any information is appreciated Soon to be SkinnyChick

<p>Is there anyone that has had trouble with BCBS of Tennessee? I'm in my 50's and already had 2 surgeries this year. Do you think they would say no because of this.</p>

My case is with the National Appeals Unit (I have Cigna) and Walter & Kelley Lindstrom have been helping me with this. Kelley is anticipating a denial (based on her experiences). The next step would be an Appeal Hearing. Has anyone gone this far in the appeal process? I know I would have to attend but not sure what to expect. The Lindstroms will advise me but since they are in CA and I live in TX I'll be attending this alone. Has anyone attended one of these?

I have Blue cross blue shield of Kansas City and have been denied because of an exclusion on the policy. What do I do now. Can I appeal if there is an exclusion. Does anyone out there of BCBSKC. Please help.:cry:faint:

Hello everyone! This is my first post. I'm very excited about getting a lap band. Last week I went to a seminar given by Dr. Chua in Milwaukee and this Friday I have an appt. to see the nutritionist and the psychologist. I called my insurance and they do cover bariatric surgery however someone at Dr. Chua's office said that my insurance (WPS) does not cover the lap band because they consider it experimental. I would rather have the lap band insted to getting the bypass done. I'm wondering if anyone out there has a lap band that has WPS insurance?:phanvan:(

dose anyone have a insurance that would paid for a gastric bypass but not for lapband surgery.that is my insurance <br /> <br /> i can not have the gastric bypass surgery for heath reason but i can have lapband done . can anyone help me .

My mother called UHC today to ask if bariatric surgery is covered in our plan and they said that yes it was. She asked a few more questions about it and they basically said you need a recommendation from your PCP (not a problem), a few other documented things (saying how this would improve our lives, etc) and that was about it, which surprised me. Obviously, we both more than meet the requirements to have this surgery done, but I didn't think it would be that easy. Is this weird? Or just another green light? I know we have to go through approval and everything, which shouldn't be a problem at all. I just want to know if this is normal or not. Thanks!!

Have any of you who are in Mass with BCBS had problems getting approved? I am being submitted for review with the surgeons tomorrow,then, if approved by them,submission to BCBS? Would they not approve it if I hadn't been to a supervised WL program? My BMI is 49 and I have 2 co morbidities.... I have a gym membership(a lot of good that's doing), trying my own diets for years, but never a jenny graig or weight watchers. I've taken pills, slim fast...all that crap. Has anyone here ever been denied because of this? I guess I am freaking out a little. Thanks.

i was wondering if anyone out there has blue cross in massachusetts and if so, how are they at handling the lap band?? do they cover?? do they take a long time to give an answer??? thanks for any info !!:help:

Hi, everyone - who here has done the 3-month medically supervised diet, exercise, and psych program to get approved by their insurance (as opposed to the usual six months)? Have you been successful? If so, what did you do? If not, what reasons did they give? Thanks, all!

Anyone with experience with GHI HMO? I was curious if they covered fills and, if so, how long?

Does anyone out there have Blue Cross Blue Shield of Kansas City.

United Health Care denieds me because of "lack of objective documentation". They cover 35 BMI or more with co-morbidities, so that isn't the issue. I have 35 BMI with Hypertension, high-cholesterol, and tons of bad family history. :help:Can anyone tell me what documentation is really needed so I can get this done ASAP?!?!? Thanks for any help!

:help: Hi just wanted to know where you can find the cheapest financing with the lowest interest rate for a surgical loan. I want to have surgery but need loan. Thanks for any help you can give me. Queenie

:angry I just recieved a call today from the clinic stating that when she called my insurance company they said my policy had a pre-existing claus in it. Due to this it may not be covered. Has anyone else had this happen to them? My insurance company is BC/BS PPO. I just hope that all the testing and things I already have scheduled will not be for nothing. When I called the insurance to see if they covered this and what I had to do they said nothing about considering this as a pre-existing condition.

I'm in the process of getting insurance on my own because the company I work for has crappy insurance. I've spent some time looking on ehealthinsurance.com and so many of the policies under limitations and exclusions, state they don't cover weight loss surgery. I've looked at Aetna PPO and others, and they state they don't cover. What I really need is someone to tell me specifically which insurance company and policy name they have that is covering the surgery. Even if it's has requirements like 6 months of medically supervised weight loss or other requirements, I understand having hoops to jump thru. I'm in Texas. Thanks.:help:

I was wondering being a veteran do the VA help pay for Lap Banding

I saw someone say they got 50% financing but was wondering if it's possible to get 100% financing?

Hi everyone, I am a noob to this board and have been a bit or a lurker. Anyways has anyone had any experience with BCBSIL PPO and getting approval for Lapband? Are they going to expect me to jump through hoops or is this going to be a rather pleasent experience? Thanks for your help

I am just starting my WLS journey and am hoping to find out about your experience with TRS Activecare. 1. How long did it take to get approval? If not approved how long have you been working to get approved? 2. What is your BMI 3. Did you have to call them constantly? 4. Were you denied the first time? Did you have to appeal? 5. Any recommendations for people trying to get approved? 6. What plan are you on, 1, 2, or 3? Thank you so much for sharing this will be a huge help for me while preparing for ins. approval.

I just recently accepted a job in kansas with a school district, and the insurance carrier is coventry, I have not received my info book on them as i am just now starting mew employee paperwork, i was wondering if anyone else has been able to use coventry to get their lap band or if i should once again put this idea on the back burner....thanks

Ok, guys, I need some advice. When I went into my Dr's office for my first consulation (Which was on 4/27/07), I went in basically prepared to self pay. Well first of all I have to submit to my insurance company, just to make sure they won't pay. They have a list of things my insurance company requires. (Pulmonology, Cardiology, Psych, and 3 *or 6* month supervised diet) Well I have dieted all my life (Trimspa, Ediets, Weight Watchers, the plain and simple 'cutting back') and have always lost, but then gained the weight lost, and then some. I have no documentation of this from any of my physicians. My concerns are these, in my insurance packet (I have First Hea…