Insurance & Financing

Hoping someone can help clarify, since I'm not insurance-savvy So I called my insurance plan and asked if they cover bariatric surgery. They said they do, but need prior authorization from the surgeon saying it's medically necessary. When I asked about requirements, nothing was said about a 3 or 6 month diet, only a BMI greater 40 or higher or 36-39 with one co-morb. Does anyone know anything about the process of getting prior auth? Is it a long process? Is it something that may slow the process? Also, if 4 different insurance reps said nothing about a supervised diet as a requirement, does this really mean there is none? Just some confusion about the prior authoriz…

Has anyone had problems with insurance denying for failure to lose weight on the supervised diet prior to surgery? That is the last thing I am waiting on and would hate to get denied because I didn't lose any and actually gained a few pounds!

I've been following the Medicare approval process because as I understand it Tricare will not cover VSG until Medicare does. The Link Below is the supporting letter sent from American Society for Metabolic & Bariatric Surgery. Please if anyone learns any more about successful civilian Tricare coverage please share!!! http://s3.amazonaws.com/publicASMBS/GuidelinesStatements/PositionStatement/ASMBS_CMS_Sleeve_Letter_Oct_28_2011.pdf

Just wondering if anyone here has gone through BCBS of Alabama? How long did it take for approval? I still have 2 months before I submit everything, but I am curious to see how long after that ill have to wait. My surgery coordinator said she could get me approved fast after I finish my 6 months and get a 3 year weight history, so my fingers are crossed for that!

Has anyone had experience with Cannon Cochran Verity Healthnet? I am a government employee. I have been to the first meeting with the surgeon's office and the dietician. I was told that I have to do the 3 month medically supervised diet and psych eval for the sleeve. I have a 48 BMI with hypertension. I also have chronic joint pain and arthritis. After the first visit, I was excited and began the one meal replacement diet. Then, I saw my PCP's nurse when I went to go pick up medical records and she said not to try too hard to lose during the diet or I might be denied! WTH? I'm now really confused! Any advice about the ins company and/or the diet? Thanks ahead of tim…

Paperwork was submitted to the insurer a week ago. I called this AM to check the status. I was told in a very condescending voice by the reviewing nurse that this process would take 'a very long time.' She said that she was waiting on a call from the medical examiner because she wanted to discuss with him what to ask my surgeon's office about other weightloss programs that I have tried. I said well, next week is a holiday week and I just wanted an update before people went on vacations, etc. She said oh, you won't hear anything next week! This process takes a very long time. WTH?! Do these people sound like they are looking for a reason not to approve me or what? …

Has anyone in Louisiana had VSG? If so, which insurance company approved you?

Just found out yesterday that my insurance approved me for the VSG! I just need a sleep study, which I will get scheduled on Friday. I have my pre op appointment july 12! :-D

Now im sitting here anxious and nervous. Please send some good vibes my way. My surgery is scheduled for July 2.

i have tricare prime insurance and will start receiving fills in the coming months. what is the procedure? do i need to get referral from my pcd and have them submit for approval? if so, how many fills do they allow or is there a set limit? do you pay the co-pay? what if they do xray, do you need special referral/approval for that?

So after long and hard consideration I have decided that I wanted to have weight loss surgery and that the vertical sleeve is the option best suited for me. I started my journey at 377 and through diet and exercise I currently weigh 338. I spoke to my primary care physician about being referred to their Options program and she flat out told me no. I get the impression that her refusal was based more on personal and not medical opinion since she had nothing positive to say about any type of WLS and essentially was not truthful about the type of surgeries offered to Kaiser patients. I am in the Downey/Bellflower area and do not know what to do. Does anyone know of a PCP i…

According to Cigna they only require 3 months of consecutive PCP check-ins - so with that said, I started documenting with my doctor in May - does the visit in May count as #1 or does the visit in June start as #1 as May started the process and first check in was May? So, will May, June and July visit suffice? Or will they look at it as you started working with your PCP in May - first visit June, second visit July, third visit August. Make sense?

I met with surgeon & pa and did the pre-op physical today. My insurance has not yet approved the band...so I called them & the hospital never sent over my packet. I have surgery scheduled for a week from tomorrow so it will probably get delayed due to this oversight. Just a word of warning-if you are waiting on insurance approval-be sure to call them to make sure they received the paperwork! They faxed mine to insurance today but due to the short time frame surgery date cannot be guaranteed. I'm so disappointed since everyone at work scheduled their vacations around my surgery to help me out...now I feel like I put everyone out!

My insurance covered 100 percent of my surgery i had to pay only 200 and its being refunded! Its a good day!

How did everyone do on their preop 6 month diet? I am currently a 41 BMI, my surgeons office said that I can lose any amount before surgery and still be approved. I am losing weight and following directions, but worried my insurance will say I'm now below a 40 BMI and deny me. grrrr.. I hate the worry with the insurance approval process. I started the 6 month diet in april, and just met with the new surgeon a few weeks ago. Anyone else go through this?

I am still confused with the Medicare approval (?) of vsg. I gather that it's a state by state and case by case basis? I am curious now if Tricare will follow. I know some people in the wls world know how long it has take different insurance to approve different surgery types. Does anyone know how far behind Medicare Tricare was for other surgeries? Just trying to get an idea on how long I'll be waiting. If it's only going to be a few months I'll definitely wait to have it done by my civilian bariatric surgeon, otherwise I'll go forward to have it done at an MTF. I'm meeting with my surgeon tomorrow and plan to ask him as well, but I'm anxious for any info.

Hi! I am a newbie and I started my lap band journey on 6/26/12 (attending the seminar). I am 44 years old and have a BMI of 37.5. I have also been diagnosed with high blood pressure. I know that BCBS requires at least one comorbidity if a BMI that is lower than 40. I am wondering if anyone is going through the same situation as me (or similar). I am still going through the early process, but wanted to know if BCBS has given anyone a hard time about approving the lap band procedure (with a BMI < 40 and at lease one comorbidity). Thank you for your input in advance.

Just talked to the surgeons office and found out all of my paperwork was sent in to Cigna today!! Now it's a waiting game. I'm very excited and hope all goes smooth. Wish me luck!!

So, after being so optimistic about this entire thing...I call my surgeon today to ask a few questions about paperwork and she tells me that my isurance (Medicare) does not cover sleeve gastrectomy. What?! I have printed material given to me by her office that states that it is. What's the deal? I'm so confused. Not to mention the insurance coordinator wasn't the friendliest person I've met. So I have an appointment on Wednesday to see the nutritionist first (to whom I have to pay a $250 fee non-refundable) followed by an appointment with the surgeon. I think I will ask to see the Doctor first and get things cleared out with her insurance coordinator. All the insuranc…

Hi I only need my last visit then my file will be submitted?!just want know has anyone got denied with the insurance i have now?! Highmark bcbs pittsburgh...

Sooo I'm in the waiting stages of getting final approval from my insurance company. And I hate waiting!! Lol So my question is how long did y'all have to wait until you got approval and a surgery date? I have Cigna if that helps! Thanks!

Does anyone have Cigna as their insurance carrier? How long did you have to wait before getting approved? Are they decent to deal with? I've heard horror stories about some insurance companies.

Ok, hopefully some people who have already been approved can tell me if I have messed up here. Due to my work situation I had to schedule my days like this: Feb 21 March 26 (34 days apart) April 23 (28 days apart) May 21 (28 days apart) JUne 25 (30 days) July 24 (29 days) It would just be awful if I was denied on a scheduling technicality. Anyone have any insight??

have insurance companies lowered the required bmi requirement? particulary horizon blue cross blue shield.

Hi everyone. I am just beginning this whole process. I'm from Northeastern Pa, 25 years old. I have gone to my doctor and he supports me getting the VSG done. I have BCBS of Nepa, First Priority Life. My insurance covers the surgery. They do not require a 6 month supervised diet. I just called the Wilkes-Barre Bariatric Center yesterday and registered to go to a seminar on July 19th. The woman that I spoke to said that the process usually takes about 3 months with them. I feel confident in having all of my requirements for insurance approval except the required "5 years of recorded obesity". I'm nervous because I have been going to the same doctor since 2005 but…

My wife had her VSG in August and is doing well. She has been in contact with Medicare to get them to pay for her surgery. Based upon her request, Medicare did a study regarding the feasibility of the VSG for those on Medicare. Their report came out last week and indicated that although the VSG is as safe or safer than the bypass, it could NOT be approved because any research done on the VSG utilized too small a sample size. I am requesting anyone who has had or is contemplating having a VSG and is on Medicare to contact Medicare with your outcome with the VSG Medicare is seeking PUBLIC COMMENT regarding whether the VSG procedure should be approved. It could help fut…

I have a surgery date of August 23rd, hopefully all will go well on the financing portion. The majority will be covered by insurance that will pay for the Hernia Repair and I have to take care of the lap band portion. True Results is supposed to let me finance that portion at $266.42 for two years, if not then I may have to delay until January and up my FSA. Fingers crossed!

So my primary doctor decided not to clear me for surgery because he doesnt believe in the surgery. He knows ONE person who had complications and died. Now, that doesnt mean I will have the same situation. My insurance approved the surgery and I have my date set for July 17th. I am sooo upset. I can't believe this doctor is ruining this for me. I am seeing another doctor tomorrow and hopefully I can get my clearance.

I got a call last month from my dr. office saying I was approved...brought me in for my pre op appointment. Later that day I was called and told that No that they hadn't gotten the approval and that I might have to do the 6 month I can change program (tufts). it's been two weeks and they kept asking for more and more paperwork, which my dr. office kept sending them last night they denied me. missing clinical paperwork missing! My dr. office calls and tells me that she's working with someone and that she is going to resubmit it with the missing stuff. I call and as questions ( I hate waiting!) and the insurance woman tells me that no a denial is a denial and that my Dr. ca…

I am post op 3 months now and just recently received a surprise bill for the surgical assistant for $2000.00. My insurance will only allow $250.00 payment. I called the billing dept for this assistant and received a rude customer service rep stating that they will not accept any payment lower than the total amount due since the SA is not covered by my insurance. I did not have the opportunity to pick out the SA only my doctor did. Has anyone else experienced this predicament? That's $44.00 per min charge for a 45 min surgery.

I have a question... I have a consult set up with the bariatric surgeon for July 11th and when I initially talked to them, I was pretty sure that I wanted to go the RNY route. I have since done tons of research and realized that the sleeve would be best for me and my goals. I was told when I spoke with them that my insurance was pretty easy going and they typically get quick approvals for the RNY from them. I have Anthem BCBS. Does anyone know if they cover the sleeve as well? I am 5'4 and 270 lbs. They said my BMI was around 46. Thanks in advance!!!

Anyone have just straight Medicaid for their fills, my insurance for the band was anthem (through Medicaid) but my anthem lapsed the day after surgery, I'm due for my 1st fill next week & was wondering if anyone has had Medicaid approve the fills?

Medscape Medical News from the: American Society for Metabolic and Bariatric Surgery (ASMBS) 29th Annual Meeting June 17 - 22, 2012; San Diego, California http://www.medscape.com/viewarticle/766243?src=nl_topic http://www.medscape.com/viewcollection/32520 Sleeve Gastrectomy Gets Boost in Push for Insurance Coverage Kate Johnson June 22, 2012 (San Diego, California) — With a final decision expected within days from the Centers for Medicare and Medicaid Services, there is now ample evidence supporting the agency's full coverage of laparoscopic sleeve gastrectomy (LSG), researchers asserted here at the American Society for Metabolic and Bariatric Surgery (ASMBS) 29…

i am so confused. whats the difference? apparently my paperwork was in the determinatiin queue and should have ben in the certification? idk someine kniw the difference????

I was denied when my doc. sent in my stuff to ins. (bcbs) I have bmi of 38.5 and moderate sleep apena. My policy on wls says severe sleep apena. I told my case manager and the Dr. this but they said don't worry about it. BCBS is easy and we can get you approved. So I got my hopes up big time! I am $500 approx. out of pocket for all these tests that I would have never had done. I know my doc. office can't garuntee me anything but they do this all the time and I got fooled! My doctor did the peer to peer today and was still denied. What should I do now? I am so upset and discouraged. How much is Mexico? Does it include airfare? thanks

I'm in Lawton, Oklahoma and would like to find a military facility that performs the sleeve. Has anyone in south Oklahoma or north Texas had it done that has Tricare?

I've been losing every month until today..my 5th weigh in I gained 7lbs!! I have BCBS of Alabama and a bmi of 61..I pray that I can still get an approval:(

I have been denied three times by BCBS of IL and now I have t write an appeal to go with my surgeons appeal. I was wondering if anyone else has been is this situation and what kind of things you said in your appeal. I am very frustrated at this point. I don't know how much longer I can do this. The approval process is very stressful. Any info would be appreciated. Thanks.

Anyone have experience with Altius Federal and the sleeve? Thanks. Christi

I have a Hiatal Hernia and will get my Lab Band in conjuction with my Hernia repair. The cash price for the Lap Band portion is $5500 and True Results will let me make payments for the lap band portion. Has anyone had experience acquiring Lab Band this way? Hoping to have the surgery in September.

Anyone have experience with Altius Federal and covering the sleeve? I am just starting my journey and would like to know what to expect. Thanks. Christi

I was supposed to have surgery May 23rd. BCBS Of AL denied it because of the nutrition part. They said that that the nutrition part that I did with my doctors office wasn't good enough. So I am waiting on a Peer to Peer Review that should be done this week. So I am hoping that they approve my surgery.

HI MY BENEFITS START 8/1/12, I WILL BE COVERED BY BCBS ANTHEM THROUGH MY EMPLOYER...IT HAS A $2000 ANNUAL DEDUCTIBLE AT 80/20 AND A TOTAL OUT OF POCKET DEDUCTIBLE OF $4000 AT 100%....I HAVE ALREADY WENT TO A SEMINAR..I SCHEDULED MY PRIMARY DOC VISIT FOR 8/2/12 IN THE A.M. AND MY INITIAL BARIATRIC CONSULTATION FOR 8/2/12 IN THE P.M...AT THE SEMINAR I SPOKE WITH THE FINANCIAL LIAISON THAT WORKS FOR THE DOCTORS OFFICE....AND SHE WAS EXCITED ABOUT MY INSURANCE PROVIDER...SHE WAS EXTREMELY CONFIDENT IN REASSURING ME THAT AS LONG AS I MEET THE REQUIREMENTS FOR THE SURGERY(IM 33 YEARS OLD/5'8/480 LBS/BMI 72.98/SLEEP APNEA) THINGS WILL GO SMOOTHLY AND QUICKLY...I ALREADY KNOW THA…

This afternoon we submitted my paperwork to Cigna. I have a bmi of 41 with no other health issues. I quit smokin 4 & 1/2 weeks ago and I have been eating healthier already. I am so ready for the anxiety of not knowing to be over. two more hurdles...insurance approval then apply for financing for my out of pocket portion. I will be on pins and needles lol. Any prayes or well wishes is greatly and deeply appreciated.

Hey everybody, I have been stressing over how to approach the subject of the sleeve with my PCP who is a huge advocate for the band. I've come to the end of the process and the only thing standing between me and insurance approval is the freaking letter of medical necessity for Cigna. Here are some ideas I'm thinking about on how to sway my PCP at my appt next week: 1. Bring the surgery packet my surgeon gave me that outlines the differences between the two surgeries, and show her how the sleeve is better for me(I have Type II DM and HTN and as far as I know, the band doesn't do as well of a job resolving these issues as the sleeve). 2. Type up a letter as a guide (i…

What's the max/min anyone has paid out of pocket with insurance?

Hello, My insbcbs) has denied me 2x. 1st when my information was sent in and 2nd when the doc. did the peer to peer. I am trying to do an appeal and my case manager wants to know if I want to write a letter to send in with it. Does anyone have an appeal letter(that worked) that I can get some ideas from? bmi - 38 Co-morbidity - moderate sleep apena - ins. says it has to be severe sleep apena. I had irregular heart-beats and my oxygen level was very low, guess it wasn't low enough. other problems that ins. does not care about - depression, joint pain, high cholesterol, fatty liver. Just don't know how to start the letter and am so upset and down I can't even t…

I have been approved! I sent in all of my paperwork on June 11th and they closed my case because I did not have a physical or bloodwork within the last 60 days. The third party (Alicare) also insisted that they had their own requirements seperate of what is in my benefits summary. I argued this point, andI went for my physical yesterday and bloodwork the day before. I submitted the updated information this morning with a somewhat personal letter. Less than a few hours passed and the Union had called to say that they had waived their right for third party approval and have approved my surgery! In case anyone is wondering, my insurance is Cofinity.

Well, it's been officially over 6 months since my first appeal being denied which means,supposedly (according to my job's insurance contact), I can re-sumbit my full/complete packet for surgery once more. This time they will submit as a whole new request. We have gathered additonal and new documents so if i dont get it passed this time, i'm out of luck for surgery (selfpay is not an option for me). Through countless appeals (another long winded story in itself) and my insurance not giving accurate information, this process has been excessively long/draining/frustrating. I still have a complaint filed with the state's (pa) insurance commissioner. Whether it helps my c…

any experiences with either? hopefully only need to finance my out of pocket portion $3900