Insurance & Financing

My wife submitted her surgery request to BCBS of Texas along with supporting documentation from our PCP, lab work and Dr. Jayaseelan's recommendation and she was approved with ne'er a whisper. I'm still pinching myself...

Well I just wanted everybody to know that I am ready to stop beating a dead horse. I just got notice from my employer that they are not financially able to add the ryder that I would need from the insurance company in order to have the surgery. Initially Paramount HMO (my insurance company in Ohio) said they had an exclusion. Now I believe they do allow the surgery if the employer adds the ryder. So now it appears that my employer is the one with the exclusion. I haven't talked to HR one- on- one as I just got the notice yesterday. I plan to see what's up. Right now self pay is not an option. I had made a decision to turn this over to God and said I would accept w…

wish me good luck! I did find out that my dh boss really cant do anything to change the policy b/c Anthem controls the plan and they do not "self pay". So this appeal is my only hope then if I want to go further I have to sue them. I cant go before a independant appeal board b/c it has to be that they are denying me due to medical necessity and that is not why they are denying me. I really really hope I can get this approved! Jill

I hired an internet lawyer last February when I was denied by Anthem BCBS as experimental. I was rejected for the next two appeals (I was told there were two appeals..I only got a notice for one). In June I went ahead and went selfpay. Now I find out that my insurance company started approving the lap-band in mid June. I emailed my "attorney" and he said that they would file another appeal. Should I trust him? I'm worried that come the first of year that the insurance company might make another change to the worse, if something isn't done soon. Cathy

Here are names and numbers that I thought might be helpful to those of us that can't seem to get anywhere with insurance companies or those of us who don't have any insurance at all .. I hope this information can help someone who is struggling to get banded so that they can have there life back such as I am .. Good Day to all ! Capital One 1-888-440-2375 www.cosmeticfeeplan.com APF Advanced Patient financing 1-800-392-5189 www.APFUSA.com Reliance Finance Corporation 1-800-322-6377 www.reliancemedicalfinance.com The Surgery Finance Center 1-888-942…

Dh talked with the president of his co. today about the fact that the insurance denied me, and the whole saga. His boss said he will do whatever it takes to get it approved for me!!!!!!!!!!!! YEAH!

My first appeal was denied before they even got my paper work or appeal letter. It was denied based on me saying "I want to appeal, send me the forms" They sent then but sent me the denial before they really even received the forms based on the new "exclusion" they inacted the day my surgeon requested the procedure. hmmm these people are really shady-- so now I am going to stand before their board of appeals with their Dr's RN's and lawyer and such. I am not a bit intimadated at all-- this is probably a good thing b/c they wont realize what is coming at them is a strong, determined, and educated person. I think my Dr is going to join via conference and I may have a la…

Thank you Horizon Blue Cross Blue Shield! My surgery is next Tuesday!

Well I faxed my stuff in the 1st in the afternoon and I sent in certified mail too. I got a letter dated the 2nd denying the appeal for the same reasons. I want to know how they could have got my letter read it and denied that quickly they cant do anything overnight and this was less than 12 hours ????

Please help I have just started thinking about the surgery and I am scared i won't get approved by insurance. 280lbs and I have been heavy all my life the last time i was thin i was 7 yrs old. Is it that hard to get approved

Need anyone's help that has been approved with M-Plan. Require 18 months of doctors suprevision care, but wont count time on Meredia or Adapex even though under doctors care with weigh in blood work, etc. Have done Weight Watchers, tops, Curves, LA Weight Loss, OTC Diet Pills- but not under doctor's care, doctor may have known about it but it's not in there notes-What do I need to do!? I'm getting discouraged-Does anyone know or have used some sort of advocate. This is my second round through my second insurance company. I appreciate the help. Kadtie (Still Hopeful)

Well I sent it-- actually I faxed it and I sent in certified mail too. My dh talked with his HR person at work and she wasnt even aware the coverage was dropped on November 1!!! ( the same day I filed my paperwork to be approved) Err anyway we will see from here. I have to wait 20 business days to hear the answer and then I will contact a lawyer if need be. I really hope we dont have to go there! Jill

Does anyone use aetna and have been approved? is it hard to be approved by aetna?

Just wondering?

This is the letter I came up with for my insurance co. Please tell me what you think or if I should change anything. I used parts of letters I found on the net and added my own issues to it. Here it is any advice would be helpful. November 25, 2005 Dear Sir or Madam, This letter is to appeal your denial for LapBand Bariatric surgery procedure code 43659. I was referred for this surgery by my Endocrinologist, my Gynecologist and my PCP, whom are very concerned about my health because of severe morbid obesity. I am a 30 year old morbidly obese female who is 4’11” tall with a bod…

http://news.yahoo.com/s/ap/20051123/ap_on_he_me/obesity_surgery

I would like to know what i will need for insurance to approve me, and how much out of pocket will i need to come up with? Do I need to come up with the money ahead of time for surgery or what? Does medicaid cover this surgery?

I have Humana and am afraid that will deny me. I fit the criteria for the lapband but it is excluded from my policy. I want to fight it if they deny the claim from my Dr. But I haven't the slightest of what to do...Can anyone tell me what to do because I'm afraid they will deny it because of the exclusion. I have no clue who to contact or anything.....

Hi everyone, I am in the process of getting my lapband. I am on my second month of dieting and seeing a nutritionist. My question for anyone is with bcbs highmark did they pay for your surgery completely,or did you have to come out of pocket? I know i need to pay for copayments, but just unsure of what the surgery would cost, thanks for any input! have a wonderful day!

Was just wondering if anyone had been approved by their insurance company without a consecutive diet trail. Will letters of "recommendation" from your doctors work? I have dieted for YEARS, just don't have it written in a chart every month. If you were approved, how did you do it? Thanks!

I am currently seeking the lap band procedure. I have been going to the doctor for over 6 months. My current insurance is Humana PPO, but my company is switching to United Health Care PPO in January 2006. I noticed they have an exclusion for surgery related to weight loss including surgery for the morbid. I contacted them and they said the surgery is excluded. Since I have already been under the doctor's care for 6 months isn't there some way to have this covered. My doctor is trying to get my blood pressure down before they submit the request for approval. My BMI is 40 and my blood pressure is hovering around 168 with medication. My doctor said it needs to be in t…

Has anyone been approved or denied for Lap Band with the BCBS Fed insurance plan? I've had a couple of doctors tell me that they won't pay for it. I've also heard that they don't pre-approve and I'm wondering if that is the mix up. Thank you!

I am so hurt...My insurance - United Healthcare has an exclusion on my policy. My company did'nt buy the Obesity part. I am so hurt, I could just die. I know this insurance will change my life and I am ready for a life changing event. I will not stop until I get this surgery. This is my dream and I am going to make it come true. Any suggestions anyone ??? Do you know any tricks of the trade ?

I am so happy I went to my PCP on Thursday and we easily documented 12+ consecutive months of medically supervised weight loss attempts. Seriously, if there is anyone out there who must have the 12 consecutive months of medically supervised weight loss attempts for insurance approval go to your PCP and talk to him/her. My PCP pretty much had it figured out before looking at my records. Heck, she even signed the letter my surgeon uses for insurance approval. Through conversation w/my surgeon's office I think this is the biggest hurdle I had to clear. I will know better once I seen my surgeon on Tuesday.

I have to submit a 6 mo. MD supervised weight loss attempt w/ weight-ins letter to my doctor for the insurance company. I will hopefully get this letter on Wednesday when I go see my PCP. Does any one have to do the same thing? And if so do you have a sample letter. I would like my PCP to get this done ASAP.....

Hi there, i'm planning to go for the lap banding within afew months and willing to pay for it but then thought that if i could get an insurance that covers the procedure yet still gives me the rest of the year of health care coverage then that would be much better, even if the insurance plan it self is to cost the same amount the lap banding would. so is there any insurance plan that covers the procedure even if it comes at a very high price ??? Thanking you ...

i HAVE GREATWEST HEALTH CARE THEY HAVE 7 REQ. I HAVE ALMOST FINISHED ALL OF THEM I JUST NEED TO HAVE A HY PYLORI TEST NO PROBLEM BUT THE DOCTOR i HAVE BEEN SEEING FOREVER DOESN'T BELIEVE IN WEIGHT LOSS SURGERY SO i CAN'T GET A REFERRAL FROM HER. AND WHAT IS THE DOCUMENTATION ASPECT OF MY DIET HISTORY DO i NEED TO WRITE IT OUT OR MY DOCTOR? hELP ME OUT PLEASE. CURRENTLY 236 GOAL WEIGHT 140

I keep reading that some insurance requires psyche exams, sometimes sleep apnea tests, and sometimes a stress test. Would like to know exactly what tests are required before surgery. Is it different for each person? Also, I had a nuclear stress test two years ago. Do you think that would work? Or do the tests have to be recent? And about Dr reports on diets, what are the requirements? I was put on a low carb diet after I was released from the hospital for chest pain (Atkins same time as the stress test). My OBGYN put me on it for my PCOS/HBP/insulin factors. He may have it in my chart. Went from 320 to 285. I have tons of proof of using the product (receipts), b…

This is my first posting and I have many questions!! I have Anthem BS/BC of KY, PPO. Has anyone had any luck with this insurance? My policy handbook does state "medically necessary". I am 46, 5 ft 7 in @ 254 lbs. I feel I fit the criteria for a Lap Band but I am really concerned the insurance will laugh at me. Any input will be appreciate!

This insurance thing is killing me. I have the BMI and weight necessary for approval, but the documentation of supervised weight loss is a problem. Forget the fact I have tried numerous times in my life w/Weight Watchers, Sugar Busters, calorie counting, working out, etc... to lose weight and keep it off. Forget the fact that I am over 100lbs overweight, have high blood pressure, high cholesterol, and arthritis so bad in my knees I can barely walk 100 yards. Forget the fact I do have 6 months of documentation of a medically supervised weight loss program. All the insurance company is worried about is 12 consecutive months of this bleeping documentation. Here are my q…

Okay, this is the thing .... My insurance - Cigna told me they do not cover gastric bypass, but they will cover the LapBand, BUT, (and the person on the phone made this emphatically clear), ONLY IF IT'S A MEDICAL NECESSITY. Okay, if it wasn't a "medical necessity", I wouldn't be asking about it. Or, do they think I just want to have unnecessary surgery because they'll pay for it? Soooo, I went to my doctor, who is NOT a supporter of weight loss surgery, and would not support me. Fine, I'm seeing another doctor later this month. I'm going to let this doctor know bluntly I'm having this surgery. You can support and help me with this, or I will find another doctor who …

Well, I was verbally told that they approved me for the lap band surgery but the doctor wouldn't set the date until they had the letter in their hand. Well I got the letter today and they approved me for the Gastric Bypass not lap band. Guess I have to wait until Monday to see next steps I have to jump through. I'm so tired of this crap and so emotionally shot.

I just made my first inquiry call to my insurance company (UHC-PPO) to request a status update on my case (approved?, denied? need more inf???). Anyway, the person that I spoke with told me that a letter had been sent out on 10/6 with the information that I was requesting. I asked her why she couldn't just tell me if I had been approved or denied, and she said she couldn't, I would have to wait for the letter. Does this seem normal to anyone. It seems like I have read a number of posts where people have been able to get their status over the phone. Should I take this as a bad sign?? Also, as an fyi, I do know that there is NO exclusion in my policy and that UHC confi…

Which insurance companies cover this surgery. Please tell me the ins and outs of what you had to o through with your insurance company, how long it took.

Hi- I am 25 years old from North Louisiana (Shreveport-Bossier area) I am having lap-band surgery in 2006 but our insurance doesn't cover the surgery. Blue Cross Blue sheild of Lousiana is our current insurance, but weight reduction is excluded. I have PCOS (polycystic ovarian syndrome) angina, lower back pain, high blood pressure and asthma. Because of PCOS my husband and I are unable to have children. Lap-band is our only hope. If there is anyone who can give is just a little bit of information please send us a reply or drop us an e-mail: queenbuttafly@yahoo.com I pray that there is someone who can give us some information to help us. Thanks. "With God nothing…

I know all policies are different but here's something to look out for... just incase. Beware, if you need a predetermination # before your surgery, make sure your doctors office sends the information in at least 4 weeks b/4 surgery. There is a policy that they need a full 21 days before sending out an approval (bull kaka). FOLLOW UP FOLLOW UP FOLLOW UP... call them a few times a week to make sure they got your records from the surgeon. My surgery will probably be postponed a few weeks because neither my doctors office nor I knew about this "21 day" rule. WHO KNEW!!!! I was / am scheduled for Monday October 24th. I am just so besides myself right now that I co…

Well, we are truly on our way. I have a date for the surgery. It is Nov. 10. Can't wait. Scared and Excited at the same time. On our way for a long vacation to San Fran, so I'll talk to everybody when we get back. Carolyn

Im 27 years old. 5'3 259 pounds. My BMI is 46. Ive been researching lapband for a few months, finally decided to call my insurance to see if it was covered, and was given some wrong information. Long story short, my doctor has given me the thumbs up for surgery, but now insurance is telling me something different than they originally told me. Other than joint pain (back, hips, knees) I have no other signs other than obesity. My labs are fine, Im not diabetic, and my blood pressure is perfect. I have an old back injury from 4 years ago thats aggravated by weight, I see this as my only "in" to getting insurance to cover it. Im a CNA, and caring for people is my passion…

Oh what an emotional roller coaster this has been. Today the doctor's office called and talked with the insurance company. They use the same procedure for all gastric surgeries. They have about four surgeries that they approve and one or two they don't allow. But I can have any of the ones that they approve, it doesn't matter to them. They said they always use Gastric RNY as the default auto form letters that go out but it really means RNY, AGB or any of the other two. So it looks like November - here we come...... Carolyn

Im APPROVED I cant believe it my insurrance company approved me!!!!!!!!! And get this all I have to do is pay 20.00 for pre op visit, surgery, facility and DR. I was skeptical about it at first because I want to have a baby and am undergoing fertility treatments now but they say I will not need them if i get the weight off. So I guess I will go through with it. MEL

I am so stressed out Cigna denied my lapband again todayand I am really steamed! I did their little 6 month diet thing and they still denied it because during my 6 month diet I had to have knee surgery so I was told by my dr not to take Meredia because of the anesthesia risk for 2 weeks. She did not tell me go off my diet just not take the pills. So Cigna took that and ran with it even though their guidelines do not say that you have to take diet pills in the first place, just be on a diet. Cigna is using this as a loophole and its a load of crap and they know it. I HATE CIGNA! I am done, I cant take the stress of this anymore. It is open enrollment at work until Fri…

I have HMO Blue of Texas and they have that doctor supervised diet clause before they approve the surgery... I was wondering if maybe the 2 diets I did with having my kids ages 5 & 10 would count for their requirements?? I had gestational diabetes so I saw the doctor all the time and was on insulin and diet and lost 40 lbs with each kid but gained it all back. I would be so scared to try and pay for this myself without the insurance backing me up b/c what if something went wrong... I might be able to pay off 15,000 but complications could mean so much more money I couldn't ask my family to take the risk..... any advice would be appreciated. thanks…

Hi I am in the process of getting my insurance to pay for lab band, they want me to go thru a dr program 1st so I will, does anyone know the code for morbid obesity? I want to make sure my Dr. office is filing it with that code, so there is no questions from the ins co. Thanks Trish:Bunny

I hate ins companies specifically mine. I was denied for not being medically necessary. They claim they did not recieve nutritional, psych and medical evaluations and diet hiistory. The very idea. Anyone who is a pt of Benavides knows you have to do all these things prior to them submitting. They sent in 163 pages of medical documentation including 5 different letters of reccommendation from my various specialists as well as the sleep study, nutritional consult and psych consult and diet history. I have specifically been taking Meridia since May just to satisfy them. I dont even think they looked at mt file and just stamped it denied. I am so pissed:mad: I would really lo…

Thank goodness I had UHC, they took their time but they fianaly approved my band!! My Dr. says in his seminar that unless you have UHC in Florida you can just about bet you will have to self pay. Thank God I had UHC!!!!!

Ok, so I have another question. I found out that out of network things still go toward my out of pocket max...thank goodness... but my hubby pointed out that we are spending an awful lot of money for something we don't know will be approved and most of it does not go to our out of pocket max. (sleep study $500.00, nutritionist $75, psyche test $35.00, stress test $50.00, AIGB $50.00 each visit, PCP $25.00 each visit.) How many of you were denied even though you had all the pre tests done?

Does anyone have BlueCross/BlueShield Fed?

I am new here. I don't have the band yet. I am still checking into my options. I can't find a doctor near me to do the surgery. I live in UT. My BMI is 31. But I have been struggling with my weight for 10 years and nothing is working. It is like no matter how much I eat, I am not full. Just to maintain my current weight is a struggle, believe it or not. I think that mexico may be my only option to get the surgery, because of my low bmi. But I really think this surgery could work for me and help me reach my goals. I am considering Dr. Ortiz, but I am not sure. I have never been to Mexico. They said the surgery is $9,500. It sounds like Ortiz is a good doctor,…

After six long frustrating months with insurance changing it's requirements and not to mention just being a jerk, I have finally been approved. For those still trying, don't give up. Keep doing what the insurance tells you that you are lacking. For instance, I had to go on another diet for three months, but this was the diet I would be on after the surgery...the diet for life as they called it. I did that, they still denied and my doctor appealed and after 30 long days of waiting, I got the message that they approved me and even gave me the authorization number. No date set yet - but it will be after I get back from vacation on the 31st of October.

I have just been informed (by surgeon's ofc) my employer specifically excluded the weight loss surgery rider on on their group plan. She suggested perhaps the employer would add it to their plan if they knew an employee wanted it. My guess is the employer excluded it because they didn't want employees having WLS on their dime. To make matters worse, I'm not an employee there anymore - I am paying my health insurance premiums via COBRA. In any case, is anyone aware of someone having a successful appeal (due to BMI, co-mobities, medical necessity) when the group's policy did not include WLS? Thanks.