Insurance & Financing

Has anyone used or tried to use their Medical Savings Account Visa or MasterCard to pay for the surgery in Mexico?

Hi all, I just got back from Houston, with my consult with Dr. Spivak...The nurse and insurance person there were absolutely positive that BC/BS would NOT pay for my band. :cry My BMI is 34, and I both of my knees have been paritally replaced. I even had my orthopedic surgeon write a letter that if I lost 65#, which would put me at 150, it would be very benifical to my osteoarthritis. I take two medications for GERD, high chol. high tri. etc...but none of these, I was told, were considered life threatening. I don't have asthma, or sleep apnea, etc. I know, I know, I should be counting my blessings that I don't have these things, and I do...but I have had my heart se…

I am on this liquid protein diet. I am stareing at a candy dish full of SKITTLES. they are calling my name. I want to CHEW something. I am going to stay away from the candy dish but any other suggestions?

What to do????? I want to make an appointment with the surgeon for a consult which is out of pocket..$85.00-ok I can handle that. The problem is, my insurance co- Horizon Blue Cross Blue Sheild will not tell me what is required to be approved. Without their coverage I can not have this done. I hate to waste the time and money if I don't qualify to begin with. Don't I have the right to know ahead of time if I have a chance of being covered? Anyone else run into this problem??

Hi I have a Cigna HMO that did not cover my band last year so I had it placed in MX. They have now changed their position that the band is experimental and have started covering it. My question is, do you think they will cover my fills? Since there are not any band surgeons on there "list" how can I get a referral? Everyone is out of network. Will they be able to turn me sown since my BMI no longer meets their requirement? Any help is appreciated! Lisa

Just wondering how many have been approved! I am a federal employee wanting to have lab Band and my current insurance only approves RNY. Planning on changing during open season. Thanks

I have once again been...denied. The original submission was denied then, the peer to peer was denied, and now the "fair expidited review" was denied. I was told today that a company called MCMC of Boston would be doing an indepentant review. Anyone ever heard of them? From what I understand this is what they use instead of an independant evaluation. My husbands company pays them to review such cases. ~Mandy

Anyone with Aetna HMO that have been approved?

I simply called my insuarance company (BCBS of Alabama) and asked if the lap band was covered under my policy and the response I got was no. I didn't ask why or anything else as my heart dropped into my stomach and I didn't know what else to say but "ok". Could she have taken the question in terms of it being an elective thing? In other words, if my Dr. submitted it them stating health reasons, might I then be approved? I have not spoken to my Dr. about this surgery yet, I figured checking with the insurance company first was the best way to start, but maybe not. I did read on the banstersinsurance yahoo group in the database that BCBS of Alabama covered this surgery 1…

I am so confused and frustrated.... I have been waiting for approval from my insurance company. I was told all the paperwork was in and waiting for review. Then just a day ago was told that my PCP had to call and speak with a nurse to get pre-cerification for the surgery. Today I call to check and my insurance contact's line is busy so I thought I would talk to the person I got...she tells me that my policy excludes all WLS for any reason and I will not be approved...period. So I ask her why I am going through all this jazz if my insurance will not cover it...she said she did not know and repeated that it would not be covered....PERIOD! What the hell is going on? H…

Anyone Banded Has Humana Ppo And How Did It Go.....did They Pay For Your Fills

I am a relative newcomer in the midst of research. My concern is the insurance requirement that you prove you have been unsuccessful on physician-monitored weight loss programs. I cannot do that. I have never been on a physician-monitored diet (I am not qualified for various medications - Xenical, Meridia for example, due to health issues.) I went on South Beach about two years ago and lost 30 pounds - all gained back, of course. I lost 40 pounds on WW twenty years ago. So does this mean I will have to go on a physician-monitored diet, lose weight, and then gain it all back before I can be approved???? I have also read that perhaps one is required to go on the post…

As you may or may not remember I was denied with Highmark BCBS saying it was experimental. My wonderful (hopefully surgeon to be) did a peer to peer evaluation and it was again denied. The insurance company gave some out of date and totally bogus stats as to why it was not covered. My doctor gave accurate FDA stats and they refused to listen. (he was one of the FDA test doctors) He asked for an outside review and was told they would get back to him. I in the mean time called my husbands employer and Union and got them involved. That brings me to this morning, I get a call asking my why I got the union involved. It was Highmark BCBS, I gave them my entire story and she sai…

I am getting banded on June 29th. It has already been approved by insurance. I forgot to ask if the fills are covered. I have Hatvard Pilgrim, they are pretty good. I got approved the same day, actually 2 hours after the nurse submitted the request. I was just wondering, will I only have to pay the normal co-pay? I understand this may be different for different insurance companies. Thanks!

I got my denial letter today from Triwest (which is Tricare technically). It's the insurer for the military. I'm starting the appeal roller coaster, but I have a few questions for you expert bandsters and am seeking some guidance. Tricare Decision: Our determination was based on the following: The Tricare Policy Manual Chapter 1, Section 2.1, indicates that regulations and program policies restrict benefits to those devices, treatments, or procedures for which the safety and efficacy have been proven to be comparable or superior to conventional therapies. Any device, medical treatment, or procedure whose safety and efficacy has not been established is unproven and i…

Hello, I'm a new member. HI all. Okay - so I have Blue Cross of CA - HMO. I went to my family doctor and requested a referral to a weight loss surgeon to discuss lapbanding. My doctor tells me he knows nothing about lapbanding but he does know the surgeon my insurance has a contract with (Dr. Callory - spelling? - in Poway, CA). I tell him I know lots about lapbanding and am convinced it is the way for me to go and that I would be a successful candidate as I am 100 lbs. overweight, a bmi of 40, and a comordibity disorder (PCOS). We discuss other problems (I am flushed half the day - he says I'm hypglacimic - no tests - he just knows cause he is so smart - irritated…

Is Cigna that hard to get lapband approval for? I have finally heard back from the two doctors office that I am trying to get the surgery through, both of their insurance handlers sound very negative about getting Cigna to approve the surgery. One told me that I will have to come in the office to talk about it (she didnt want to talk to me on the phone about it). She is leaving me in a jam because she wants me to come in and talk to her right before I go for my initial appt(where I pay $395). The other office's insurance clerk, doesn't believe that Cigna even covers the band, we got into a little disagreement because I was looking at the statement from Cigna saying tha…

Just got a call the Colorado BCBS is changing there policy to BMI under 50 Band is no longer investigational!!!

I am researching having the lap-band surgery done but am on Medicare. Has anyone had medicare approve this procedure?

I have always considered myself a fat healthy person (is that an oxymoron??) I don't have any existing health conditions other than being fat, well let me clarify. I'm 5'1 and weigh 240(give or take a few). I don't have diabetes or high cholesterol. Although, since I started reading up on WLS I have developed back pain and have trouble standing up for a long time, my feet and knees start to hurt. Should I go see a doctor about this? I have a high tolerance for pain so I normally would just take 2 advil and suck it up, but I think these may support my insurance approval. I am also getting tested for sleep apnea. Are there anything else I can do? I saw something abo…

:paranoid I have my first consult with Dr. Spivak this Thursday. Does anyone know how long it take generally, for insurance to make a decision if you are approved or not, after all the paperwork is submitted? I am still shooting (and praying) for June surgery date, but not sure if it is possible. Thanks a bunch!

I think I've gone as far as I can go with insurance. I lost the 2nd appeal and my insurance company said that my employer didn't allow external reviews for "experimental procedures" (Anthem BCBS). I paid a lawyer $900 to handle the appeals but it's been 2 months since I've had a real conversation with him and he won't return my calls. I even tried talking to his secretary and was told that she was out of the office... she didn't even call me back. The only way that I know that I lost the 2nd appeal was that the insurance company did return my call... after three weeks. I'm beginning to feel like a non-person. Anyone know of a inexpensive band doctor around Ohio. cath…

I have been denied because BSCS has an exclusion for WLS surgery to state employees. I was told that this was more a policy of the state than BSCS, and that no-one has ever succeeded in getting it reversed no matter how many appeals or lawyers they used. Does anyone know if this is true. I don't want to go to the hassel if its useless. I saw on the main site that BSCS has recently changed for approval in Colorado and New Mexico. Please let me know if you have any info. BCW

I already know that my insurance has an exclusion for all WLS, however my husband's doesn't. If my husband adds me to his policy and that becomes my secondary insurance, do you think they would pay at their regular rate of 80%? Would I have to be denied by my insurance first?

Hi Needless to say I'm new and I have a problem. I've researched and want the Lap band. Tri care Prime has given me authorization to Wish Centers but they won't go for Lap band. I have found a number of people same situation (insurance) that have had Lap band as late as two months ago but not now. Any tricky moves ya"ll? Sent a question to Linstrom and I know they have been through this same thing before but got 11 pages of lawyer talk saying you got to pay so we can write a letter so they can still deny you but we got your money. Maybe I'm being too critical. I live in the Texas Hill Country. Surgery will be in San Antonio. Met …

I am waiting for the doctors office to call me back with the reason for the denial. I called to check the status and the insurance compny said a letter was faxed to the office and one was mailed to me today and could take up to 2 weeks to arrive. I called the office and the co-ordinator is going to get my fax and call me back.... This stinks...~Mandy

I received verbal notification that I needed to follow through with a 3-month diet monitored by my primary physician. Now I get a letter stating that it is being denied because "Our review has determined the services to no be medically necessary." I am 130 pounds overweight. High blood pressure, two knee surgeries (and about to have a knee replacement if I can't get weight relief). Diabetes & heart problems run in my family. What more do they want? Do I go on the diet hoping that what they verbally tell me is true since I complied with 100% of the first requirements? Or do I appeal now and still start the diet? This is a HUGE let down as I was so prepared…

I have a situation where three weeks ago, my doctor was sent a list of criteria that must be meet in order to have the lap band surgery performed. Now that I met all of that criteria and they have added more criteria. After meeting the first list which included showing failed attempts at weight loss for at least six months over the last two years, they have added/changed that you have to be on a doctor/nutritionist weight loss program for three months within the last six months. Can they change? How can I fight? I don't want to go on another diet for three months and find out that they then have a new criteria to meet? What are my options? Also does anybody know…

My insurance will cover the cost of surgery if I can prove that under doctor's supervision I attempted & failed at a low calorie weight loss program & excercise program for a minimum of 6 months. Unfortunatley, my doctor retired and when we did all the this, didn't document real good. I'm in Dallas - not that it matters. Any suggestions?

Hi, Guess Yall Are Tired Of Hearing From Me!!!! But Called My Insurance Carrier Today.. Said That They Have Recieved The 46 Pages Of Paperwork From The Lap Band Coordinator. They Tell Me I Have An Exclusion On My Insurance About Lap Band Surgery. Even If I Have Paperwork. Theytalked Like It Wouldn't Be Reviewed. I Haven't Recieved A Denial Letter. I Don't Know What To Do!!!! Very Upset About This.. Maybe Somebody Can Help Me As Far As This Goes And Tell Me What To Do .... Appreciate All Of Yalls Help. Hope And Pray Somebody Will Help Me. Hope To Hear From Yall Soon. Love , D…

I am scheduled to have surgery with Dr. Ortiz on May 18. I made one more phone call to my insurance company (PHP of Mid-Michigan) to verify that follow up treatment would be covered. Unfortunately, my call only raised more questions and concerns for me. I had called some time ago and had been assured that any "complications" from the surgery would be covered. Today I was told that if I presented with vomiting or internal bleeding, as complications from the surgery, those would be covered. But, if I required any "follow-up" procedures dealing specifically with the band, including its removal, those procedures would "not likely" be covered. I think in order for me…

I just got denied from my insurance(amerihealth hmo) telling me that they approve gastric bypass if medically necessary but do not approve gastric banding.........has anyone else had this experience?...what should i do??

All of my posting, whining and complaining has been done on this forum. I am happy to report that I will be posting, whining and complaining on other forums now because I've recieved my approval from BC/BS yesterday.. and my surgery has been scheduled (tenatively--the Dr's office is double checking OR availability) for June 2. Thanks to all for the information and support--past and future

i went to my doctors appointment today.. i was banded on april 21 and i had to pay.. my doc told me today that he has a lawyer that will fight my insurance company.. he said he will pay for the lawyer and if he gets me my money back then i can reimburse him....does this sound strange to anyone.. i love my doc he is a great man and i can believe he would do this but i am still a little sceptical...i guess i have nothing to lose(except weight LOL) any comments????

My insurance is having open season, any suggestions on how to find the details of what each company will cover. I have beeen to their websites and not much detail. Any help would be appreciated, my current carrier does not cover banding. thanks

I have been turned down from Blue Cross of CA. Surgeon had sent first request. I have sent an appeal letter, my Family Physican sending an appeal request and yesterday contacted Inamed for information to be sent to BC of Ca. Any Blue Crosser's of CA appealing? It's BC Life & Health Insurance-Los Angeles Lynn Y Yeagerlms@sbcglobal.net

Anybody who reads in this area may have already noticed i am looking for info on bmi <40. i have multilple physical probs, (have not had sleep apnea test) and my insurance is self administered by the hosp. i work at. i know they pay for lap band w/ "co morbids". Has anyone heard of insurance paying for 35-40 bmi. i live in New orleans, i have a surgeon picked already and know they may be kind of liberal although i haven't been to the office yet. I don't even need referrals to see a surgeon or specialists on my plan. my ins. co. told me i need a letter of medical necessity no other rules or regs.MMMMMM lisa tired of yo yo dieting and trying to prevent the diabetes, he…

Does perserverance really pay off? I guess I will know soon enough. I have been wrangling with Horizon BC/BS of New Jersey since October 2004 trying to get approval. I received a call from our company's benefits broker today. I had to involve our benefits broker because I was getting nowhere trying to deal with BC/BS directly. The last contact I had from BC/BS was January 27. At that time they requested two minor pieces of information that were forwarded by my surgeons office. I called BC/BS March 4 to see if any determination had been made. They said they had received the information requested January 27 and my case had gone back to utilization review, and it would …

I have been trying to get approval from my insurance company since October 2004. They finally determined that there was insufficient documentation presented showing where I'd been on a 6-month doctor supervised weight loss program. To make a long story short, I have had numerous medical problems over the past 2-3 years, which include hypothyroidism, fibromyalgia, gerd, sleep apnea, etc. The symptoms have all worsened in the past year. I have letters of recommendation from an internal medicine MD, rheumatologist, pulmonologist, and endocrinologist. I've had accidents caused by sleep apnea where I fell asleep at the wheel, can't get out of bed a lot of mornings and am …

I found out some info for anyone that self-paid and wants to appeal their insurance. Before you can appeal, you have to actually file a claim. You have one year from the date of your surgery to file the initial claim. If you haven't decided whether you want to fight your insurance (since it's after the fact and you've already paid) at least do the first step of filing a claim before your one year expires in case you change your mind some day. Once you file the first claim, then you've bought time for the actual appeal. You'll need a claim form with the "Universal Procedure Code." Send the claim form to your insurance with copies of your medical records and billing.…

Anybody know about Humana (aka ChoiceCare) health insurance? I am too lazy to call and be on hold for the next hour. Eventually, I suppose I will have to. Anyone know if they cover fills????

Insurance Carriers That Will Cover This? Well Im 23 Yrs Old, Im A Little Over 400 Lbs, So I Know I Will Meet The Criteria Especially Being Only 6ft. Anyways Where I Work Were Switching Insurances. Were Getting Blue Cross Blue Sheild, Or United Healthcare, So We'll See, Anyone Out There Wanna Share There Insurance Carriers That Covered This. Where I Used To Work, They Covered 80%, Why Did I Leave, Anyways, Thanks Yall!! Daniel

The hour I spent on the phone yesterday did wonders. The lady on the phone felt bad that my paper work went to the wrong Dept. just sitting there, So she put a RUSH on it.. I didnt think it was going to be within hours or talking to her.. WOW that was RUSHED!!! So my Dr.'s Asst. called and said I can have any Thursday in April or March 31. I have to wait for April to save money and vaction time. Hmmmmm what day what day hehehe OMG Im excited now.. Now I feel like im not just going on a MAYBE in April!! it WILL be in April.

I have BC BS and it is a really good policy, it covers weightloss surgery with only a few requirements. 1) BMI of >40 or 35 with co-morbids 2) failed weightloss attempts (DUH!!) 3) psysc eval 4) supervised weightloss (6 months accumlative in last 2 years) My question is this, my pcp has very few records of my weightloss attempts. She has put me on several lowfat, low cal, low cholestrol, low everything diets. But there are only records of 2 such diets in my chart. There are several cholestrol checks in the last 18 months but nothing else, she has one visit listed as reccomend diet/exercise and nothing else charted at all. They just called me and said that they w…

Hello all, My insurance company called me today after my Dr submitted all paperwork and asked for a HIPPA statement from my old job. I have been on my new job now for 8 months now. I am researching HIPPA, and was wondering why would my insurance co need this info. I have found out that HIPPA tells what your medical history is. My main question is has any other bandsters had this requested and if so, what was the outcome? Thank You Dlynn

Hello everyone, I was hoping someone might help me get started on an appeal. I am a 400lbs 5'9 36 year old male who would like to get a Lapband. I have been refered by my primary physcian to an obesity specialist who does both Lapband and Gastric Bypass. The obesity clinic has been given the approval to do the Gastric Bybass on me. When I inquired about getting the lapband instead the Obestiy Clinic Insurance representative told me that Pacificare HMO does not cover that procedure. I had previously called the insurance company and talked to a representative who said that while the lapband was not on the list currently that I should have the surgeon submit the reque…

I am self paying for my lap band while also trying to appeal for payment through my insurance (Southcare/Healthcare Preferred). Just wondering if there are any others out there who have successfully been reimbursed after self paying. Thanks for any info!

AS I told you all several days ago I have been approved by UHC. However, the letter stated I was approved but the approval did not guarantee payment...what the hay! I am trying to to get hold of someone that may answer....if anyone received the same letter from UHC will you let me know how the ayment went etc. We are covered under the railroad's contract and currently only pay $15 per visit, emergency and hospital included. Also, my doctor has not contacted me and if I have all of these tests to get set up. He is Dr. Jessie Lopez in Overland Park, Kansas so if anyone has any info on him I would appreciate that also. Thanks all for listening to me babble.

I just received notification that I have been approved by United Health Care!!!! My doctor sent in the infor on February 28, 2005 and with a little persistance on my part...I have already been approved. So, for anyone out there having problems with their insurance....be persistant but kind...I ended up in contat with one gentlemen that helped "push" it through to the right department. Again...keep the faith!!

My insurer (Aetna) denied my claim for surgery - even though it IS covered under my group plan. So I need to mount an appeal. I'd appreciate hearing from anyone who has done an appeal that has been successful...what you had to do, did you need legal advice, etc.? Thanks G