Insurance & Financing

I will try to make this short. I live in San Deigo, CA. Lap Band in 2006. Lost over 100 lbs. Lap Band removal due to slippage in Oct. 2014. Gaining weight like wildfire. Insurance denied the sleeve. Appealed with a 3rd party, Dept. of Managed Health Care who upheld insurance decision. Now I am thinking of looking into a lawyer as a last ditch effort. I am hoping someone in the San Diego area can give me some direction. Not real sure where to turn. I will have the surgery even if I have to self pay, which with my Doc. is 21,100. which will clean out my savings and put me in debt. I would really appreciate any help I can get.

Has anyone had Fallon and gotten approval. I called them and they told me they didn't go by bmi and every case is different. I am starting my journey this week and I want to know what to do to help approval.

I am in the very, very early stages of WLS. I attend the hour and a half seminar on May 18th, which is the first step in this process. I have a BMI of 50+ so I am under the assumption (from what I've read online) that the 6-month supervised dieting will be waived. I initially was leaning towards the sleeve. However, I am not sure at this point which would be best after all the reading I have done. The bypass may be an option as well. I have BCBS-Community Blue through my employer. The only information I have been able to get from my insurance company is that they pay 50% of WLS. I hope that I get more information at this seminar, but I am impatient so wanted to hear …

We submitted to Aetna on Friday. This is going to be the longest week of my life. No doubt. I'm a 41 BMI this year but was a 38 or a 39 BMI for the preceding 2 years (I was dieting. Always dieting). I'm so hoping that my constantly working to keep the pounds away doesn't come back to bite me in the behind. Fingers crossed and lighting candles. Gah.

Hello I met my potential surgeon couple of days ago. He said that my insurance (BCBS TX - PPO) requires a criteria approval process but that he can expedite it by going the Hiatal Hernia route. As in get the approval for Hiatal Hernia repair and once he is in there, he can do whatever - i.e. do the gastric sleeve. It seems a bit off the track. I am concerned that if there are any risks afterwards like denial of payment in case of complications due to sleeve if the operation was done under the guise of Hiatal Hernia. Has anyone heard of this? Is this common? What should I do?

Has anyone had experience in dealing with Aetna with a BMI less than 40? My present BMI is 39. I have not been diagnosed with one of the co-morbidities listed for BMI 35-39 . I have just been diagnosed with non-alcoholic fatty liver disease and have a GGT level that is greater than twice the high normal limit. I have been overweight/obese most of my adult life. I do have documentation of pre-diabetes A1c levels in 2011, 2013 and 2014. In 2012, I had lost 50 lbs. doing a very low calorie medically supervised diet and all my lab work looked tremendously better. In 2012 my BMI placed me still overweight, but no longer obese. I have gained those 50lbs and 20 more. …

Anyone else here in NC really wanted the VSG and found out it is not covered by Medicaid? I was really set on having a sleeve.

I am on WV medicaid, and I have completed all my pre-surgery requirements, but I found out in January that the state is changing the requirements. No one knows if I will be grandfathered in under the old ones, but no one can tell me the new requirements. To top it off, medicaid is not approving any bariatric surgeries until the new requirements take effect, but no one knows when that will be! I'm so frustrated.

After months of getting ready for this day it is finally here. I received my psych evaluation form yesterday and today my coordinator will be submitting my packet to Aetna! I pray that I'm one of those lucky ones who knows the verdict within a matter of a couple days. I'm pretty sure I won't be sleeping until I know!! #onestepcloser

Does anyone know the requirements for Medicaid? I have been told by one facility they need my PCP to verify a 6 month weight loss attempt and another facility has told me medicaid requires 2 year documentation from PCP showing I have addressed my weight issue with them. My only problem with the second one is that there were times where I went in to my PCP for an appointment but also addressed my weight while I was there so I'm doubting it was always documented. I feel like I'm lost and not sure which way to go....

I know it's just a waiting game and they have up to 30 days to approve or deny but just wondering how quickly I might hear back on this if someone else has this insurance. My stuff was submitted 4 days ago and I'm so anxious to get my surgery date scheduled b/c of some things going on with my job which dictate when I can take off, etc.

I have completed all tests required by insurance (BCBS IL) and am now waiting for approval. Waiting is so hard!! Does anyone else have BCBS IL info to share? I have heard they take about 2 weeks. Thank you!

Just got the notice that Blue Cross/Blue Shield of Florida approved my claim and my surgery on May 5th will be covered. Yayyyyyy!

I have two insurances. I have my husband's and my father's. My husband's insurance is cigna and I'm assuming it's primary. My father's is anthem. Cigna requires only 3 months and anthem requires 6. Will I have to follow only my primary insurance requirements or my secondary too?

I just got off the phone with my insurance. They said it pays 75% but the labs and doctors visit isn't covered does that mean all visits, the first one or after the surgery? Also it states I have to have documented failed weightloss attempt in the past six months. Does that mean I have to have been on a supervised diet for the past six months or just sometime in the past six months?

Hi, I am starting out in the process and my husband's ins is BCBS TX. Does anyone have any recent stories about the requirements, submission process, and approvals. I appreciate any info you can give. Thanks...

I have been told the exact guidelines for meeting the sleeve requirements (monthly Dr. visits for 6 months, psych eval, nutritional consult, BMI, etc.), and was wondering if anyone knew if getting approval through Medicaid was either lengthy or hard/denied often?

So, went to my primary today, which is part of my requirements (6 months of weigh ins). He put me on a diuretic to help me lose weight last month, but I didn't lose, nor did I gain. So, he prescribed me phentermine to help me lose the weight required to be lost before the surgery. My question is, will BCBS deny my surgery because I've taken prescribed weight loss pills? Thank you in advance!

My paperwork will be submitted to Anthem Blue Cross(CA) today.... How long did it take to get your surgery approved? Was there anything that you were able to do to speed up the process?

It's open enrollment at my job, so we have to pick our insurance plan for the next year. I plan on revising from the lap band to gastric sleeve shortly after the switch, I am confused on which plan to choose. Which would give me the best way of paying less out of pocket, for my surgery. So can I have some advice from someone who is knowledgeable in these matters. With my current plan - which is the middle tier, I pay $338 per month and it has a $1000 deductable, and it says for a hospitalization it says 90% after deductible. Does that mean I pay 10% of the total bill after my deductible? The highest plan is $539 per month has no deductible and $500 hospitalization…

I finally finished my six month weight loss requirement for my surgery. The doctor's office submitted my paper work this last thursday (2/6/14) to my insurance. Anyone know how long it might take to find out if I was approved? Am I supposed to wait until the doctor's office calls me or can I call my insurance to check my approval status? I am in Grand Rapids, MI, if that helps.

I ran into an issue today with my Highmark Flex Blue PPO 1000 insurance. The first rep I spoke to in Feb, said that I would have to cover 20% of the sleeve surgery, but today the rep said I wasn't covered at all for anything and there were no notes about the previous rep I spoke to. Because of my income I can get on Medicaid in Pennsylvania. I have been paying for insurance out of pocket, because I like my family doctor and I didn't want to have to go to a clinic. However, the surgeon's office said that it will be covered 80% and there maybe other things like the hospital that won't be covered. Has anyone in PA used medicaid for a sleeve? Did anyone in PA have a Hig…

Just wondering about their interest rates, does anyone know anything about this company?

I just had my consultation yesterday with the surgeon. I have been going to an Registered Dietician through a hospital for 2 months now. I have a bmi of 42 plus have sleep apnea, high blood pressure, degenerative disc disease, copd and asthma. Does anyone have any experience with Staywell Medicaid in Florida and the whole process. When I get customer service on the phone, I don't seem to get anywhere. Just want to know I'm not doing this all for nothing. It's like a 3 hr trip to the surgeon each way.

I will be self pay as I am overweight but have almost no problems, and never have. I am looking for surgeons who have all inclusive pricing. I am looking for someone who has their own clinic to preform the surgery. That way I get no surprises on the bills. I do not want 20 bills coming later, even if its the same price. I want to have a budget and know I can pay my bills. I prefer the Houston area but no opposed to San Antonio, Austin or Dallas. Thank you for any information.

I have Highmark BS in Pennsylvania and was wondering if anyone could share their approval experience. I am currently around a 41 BMI. I am in month 5 of my visits and basically I have gone up and down by 1/2 lb. each month. Right now I am about 1/2 lb. down from my original weight. I have an extremely difficult time losing weight, which is why I haven chosen to go down this path. I am terrified that I will be denied if I only lose a pound or two, however, to stay at a 40 BMI, I can only lose about 8 lbs. before I drop below 40. Has anyone had a similar situation? I have been overweight my entire life, have tried to lose many many times over the years, but ultimately end …

I have Anthem and curious how hard it is to get approval and also what the requirements was for others? Last year I was on a 6 month diet by doc. I took phentermine and I lost alot of weight dropped to 198. Even though I got below my 40 bmi at that time will it still count for my 6 months? Now I gained it all back weighing 254. I have no health problems and in order for my bmi to be 40 I have to weigh 248 which I do weigh more now.

Good Morning All needing a little bit of info this morning my paperwork was supposed to be faxed off last week. How long does it take them to give an answer and should I call to ask if the Drs office even faxed it yet.. im really anxious and nervous...any info would be greatly appreciated. THANKS IN ADVANCE

So i searched high and low for as much info as I could find regarding the weight loss surgery options/process through Kaiser (Southern Ca) and always came up short so I promised myself I would update others with information as I went through the processes. Basics Location: Kaiser Downey/Bellflower Okay as many of you know (or may not know) Kaiser (Socal) requires you to complete a program called "Options" prior to being approved for surgery. Part of that process also includes attending a 3 hr orientation which I did today. Bellow are a few key points I learned today. Orientation is the first step (after you are referred by you PCP. 1. The "Options" program is 12…

I posted a question a few weeks backs about "fluctuating weight during the 6month pre op diet" and if that was ok? So I have the final correct answer in regards to my insurance requirements. They say that weight can fluctuate over the 6 month diet as long as the final appt weight is less than the initial appt weight while maintaining a BMI of at least 40. So for me I'm 5'8" my first appt I weighed 272 so my weight can go up and down in the next 6 months as long as my last visit I weigh 271 or less and my BMI is still 40 so that means I can go as low as 265 and still have a BMI of 40. Just another FYI on Kentucky Passport Insurance.

My wife's employer dictates United's coverage for WLS. Only requirement: a 5 year history from a medical doctor. They do not require a 6 month diet or anything. I don't go to the doctor very often, so this is a bit of a problem. I have records from 2007, 2011, 2014, and 2015. My BMI has been over 40 since 2007. I also have a letter from another doc stating that they destroyed my records from 2006/2007 because they were so old. The insurance lady at my dr's office says that UHC doesn't count 2015. I don't have much in the way of co-morbidities... a swollen ankle. That's about it. Bloodwork all normal, no high blood pressure, relatively healthy. Which is why I never go to…

I called my insurance company today which is blue cross Blue Shield of Michigan. I was told that my insurance does not require a prior authorization however there are prior requirements that need to be met before surgery for example the six-month diet. so am I safe in assuming that my surgery is approved since there is no prior authorization required and I've completed all the requirements already? I asked the lady on the phone however it seemed like she kept getting around my question and saying there isn't a prior authorization required...

I got my Traditional Blue approval on 6 days. Didn't even have to call and nag. I'm excited to have passed another milestone !!!!

My insurance(BCBS of TN) requires me to have documentation of height and weight for the last 5 years. I have all of them except for one year (2013). My surgeon's office told me to go back an additional year(2010) but still can't obtain documentation for that year either. Has anyone else had this problem? If so what was the outcome? I hope I am not denied the surgery because of this. Thanks!

My surgeons office submitted my paperwork to BCBS Federal on April 9th. I called yesterday and was told I've been approved for a liver biopsy but still no word on approval for sleeve surgery. Does anyone know what that means? Is that a good sign that the liver biopsy was approved? Why would they approve that and not the surgery? I don't need a stand-alone liver biopsy. Any thoughts.

I have BCBS of AL which requires an office visit note from 3 years prior to surgery showing height, weight and BMI for Morbid Obesity. I have 2012, 2014 and 2015 but no visits in 2013. Seriously?? Anyone have this problem and get approved?

I just got approved by my insurance!!!! After 8 months and going through 3 insurance who at the beginning of the year dropped all bariatric coverage. I picked up new insurance and was approved in 4 days!!! Ahhh everything just became so real!!

Just curious if anyone has gotten an approval and how long it too from Boston area hopefully having surgery in wareham... Thursday is my med clearance appt

Not really "woe" but a hurdle to clear. I went through my 6 month weight loss program, got a sleep study, got a cardiac clearance, and generally jumped through all the hoops required of me. On the very day I had my last weight loss appointment, I went to work after the appointment only to be told that my company would be switching providers in 30 days. YIKES! A quick look online showed that my new provider also covered gastric bypass. After talking to my nurse navigator, we decided to wait the 30 days and then talk to new insurance company. my navigator hasn't been able to find out if I've met their requirements, so we just submitted a claim last week, figuring …

I am almost halfway through my 3 month multi-disciplinary program for insurance to approve RNY. I have done everything required so far- just have to have the last two meetings with Nutritionist and Psych eval. I am very concerned as I have gained about 8 pounds since my last visit. I know aetna's verbiage says "no NET gain." I'm not sure if this means no gain from starting weight or no gain at all during the process. I would be devastated to be denied from gaining....My next weigh in is in a week. I am fully prepared to fast in order to meet weight if necessary. Anyone have experience with this??

I'm so frustrated right now. I found a doctor I liked. His office called Aetna to check my benefits and Aetna gave them the information as in-network. So I went in for the consultation and when I got the claim they were paid as if out of network and I got a bit bill. I have already reached my out of pocket maximum for in network, so that was very surprising. Turns out that the doctor IS in network but he is not an "Aexcel" provider, which means he is treated as if out of network on my plan. Furthermore, Aetna could not even provide me with the name of a doctor on the Aexcel plan who does gastric bypasses.

I spoke with Bariatric RN at Aetna regarding my VSG Approval concerns. I just feel like I'm going to get denied, and I can't allow that to happen. I have a BMI of 41, but had a 38 BMI the previous two years. The RN said I wouldn't be denied outright for this, but that it would go to to the Big Boss for review. I am getting a letter from my PCP, stating that I have been attempting weight loss and management for 10 years. I'm also including this letter. Thoughts? To whom it may concern: My name is XXXXX. I am 43 years old and have been obese since early childhood. At age 13, I weighed 200 pounds. At age 17, I weighed 225 pounds. At age 23, I weighed 245 pounds. At …

This may or may not be a stupid question but during my 6mth pre op diet can my weight fluctuate? I weighed 272 at my initial visit I'm 5'8" that puts my BMI at 41.3 today was my 2nd mth visit I've gained 11lbs! They have me so stressed about not going under a 40 BMI that I'm gaining weight like crazy. So Dr is saying just don't go under the 40 BMI which will put my weight right at 263, so it's ok to go up and down right? But I should weigh less than my initial visit?

So, I have Highmark BC/BS and my policy has the bariatric and reconstructive surgery riders, so I just found out I was approved for both a panniculectomy and abdominoplasty, which is AWESOME!!! But they denied my request for the brachioplasty, and I have medical documentation of the same issues on my arms as on my stomach. The stomach was approved but not the arms. The surgeon's office said I would receive my denial letter for the arm lift and it would include an appeal process. I will definitely appeal. I'm just wondering if anyone has had any success with appealing for a brachioplasty or really appealing a denial for anything. Any tips would be greatly appreciated…

This may or may not be a stupid question but during my 6mth pre op diet can my weight fluctuate? I weighed 272 at my initial visit I'm 5'8" that puts my BMI at 41.3 today was my 2nd mth visit I've gained 11lbs! They have me so stressed about not going under a 40 BMI that I'm gaining weight like crazy. So Dr is saying just don't go under the 40 BMI which will put my weight right at 263, so it's ok to go up and down right? But I should weigh less than my initial visit?

The insurance company won't answer my questions about coverage & requirements for gastric surgery. Has anyone had to deal with them & were you able to find out their requirements for coverage of the surgery?

At my consultation Dr. Orris and Dr. DeBarros at WLIA (Weight Loss Institute of AZ) were very thorough going over fianancing. They went over what my insurance would cover and not cover in network and out of network. I felt the staff really goes out of there way to help you finance your procedure and look for the most fesibleroute that will benefit you. They also answered various questions I had regarding working with my insurance and how things would be processed and how they would be covered. I plan on moving forward with them at this time.

I have Aetna insurance and they require a 90 day supervised diet. I go tomorrow for my 3rd visit with the nutritionist. I am not having any luck on loosing or maintaining my weight. I have gained 3 pounds and I have been documenting in a journal daily my food and exercise. I am getting my daily water in and walking 30 minutes daily. The last couple of times I have seen the nutritionist she's only given my advise on portion control and chewing 20x per bite. She has never set any calorie ranges or other goals to work on to help me loose. However even with portion control and walking I am gaining, now I am terrified that Aetna choice POS II will deny me. My BMI is 45 and I h…

I have Cigna through my Husband and Anthems through my father. How do I know who is primary since the primary insurance is the one with the requirements.

I understand that medicare leaves it up to each state if they choose to cover the gastric sleeve surgery. Minnesota does not cover it, but I have heard that in certain instances they will cover it. Any one in MN been approved for the sleeve and what was required to get them to approve it. Thanks