Insurance & Financing

My inital claim to GHI/Emplem health was denied. My surgeon is going to the peer to peer appeal. Just sent in all the additional paperwork they requested. Has anyone had any success with the peer to peer???? I am getting really frustrated.

I was finally submitted to insurance today... and since I work at the hospital I am able to check my own referral and it is killing me so continue to see that P(pending) sitting there ready to see A(approved) so I can get on with my journey!!!.........ANXIOUS...

Did anyone use Cosmeticreit for Dr. Aceves? I was going to apply with the other company but their fees are insane. Has anyone used Cosmeticredit? If so, how was it? I didn't see anything on their website about the crazy loan fees. Any help will be appreciated.

Yay. High marks for my employer (insert eyeroll here) They opted out of bariatric coverage to decrease our costs. Anthem being one of the insurers that typically approves surgery. Anyone had any luck with getting approval with medical necessity in this situation? If not, I guess Ill be scrounging under the sofa cushions for awhile to head to Mexico. Feeling emotionally (not physically) deflated. :|

I'm currently on government health care and looking forward to find a doctor who would accept medical for the procedure. i'm located in california somewhere in the central valley. any who, I'd been looking but have got no luck at all. so if anyone knows any doc please let me know or any program that would help me. i'm 5'5 290 lbs mostly on my arms, thighs, and belly; lol i guess thats my whole entire body. i was wondering if i could get it done with my weight because my primary doctor says she wouldn't recommend me because she feels like thats the easy way out. But i told her it's a tool and not the easy way out because i would have to work hard and eat healthy for it to …

I am not sure if its my surgeon's office or my insurance company that can't get it right. My application has supposedly been submitted to Anthem 3 times. The office said they submitted my first application to Anthem CA on January 17, 2012. During this time my company downsized and I opted for COBRA coverage. Unfortunately that caused a hang up and my policy was canceled on Feb 1, but reinstated by Feb 3. Of course during that time Anthem denied my application as I was not insured. Needless to say I was not happy! The office resubmitted my application on Feb 6 for the second time. I have been calling the office once or twice a week to check on the status. All they …

My surgeon submitted my paperwork on Feb 15th. I called last week to check the status and was told that it should only take 15 days from the date of submmital. She told me they should have an answer by March 7 and to call back then. So I called today only to be advised that they haven't even looked at my claim and it was still pending. To add insult to injury he stated that since my policy doesn't require a pre-Auth (they do it as a courtesy) my paperwork isn't scheduled to be reviewed until March 14 and the soonest I could expect to hear something is March 19....my surgery is set for March 20. They are adamant about not getting to it a moment sooner. It's so frustrating.…

Have blue cross blue shield of Texas, My stuff was sent to them for approval over a week ago & I haven't made time to call them yet. Any tips on how to BuG the insurance company to get a faster response? What should I tell them if I call them several times a day like I've seen some people have?

hoping to find someone here who works for PepsiCo (or spouse) and has gone through this process already.....

I know some insurance companies will pay for the lap-band surgery. But I have the opposite problem I need my eroding band taken out after 7 years of misery and only 20 lbs loss. I have learned one thing if you have a eating disorder like bingeing or bulimia the lap band is not for you. If you just have a over eating problem and don't mind being hungry then this is for you. I live in Arizona but had the operation done in Mexico, when I went to see the doctor down there he didn't like the idea I wanted it removed for any reason he gave me a hard time so I got scared to have him remove it. Now I can't find a doctor to remove it in Arizona, and my whole body is getting sicker…

So - to be sure i understand how this works, since the surgery center of Richardson where the True Results office is located and where i'm going for all the appointments and such to 'follow the rules' of my insurance (United Healthcare-Core) I have to do my 6 months of visits plus psych eval, along with dietician consult and all the necessary 5th visit requirements of EKG/PFT and bloodwork - all are covered by the healthplan. My question is - since the Dr. is IN NETWORK - but his facility is OUT OF NETWORK - i need to make sure that when my surgery is scheduled - that it is at a hospital that is IN NETWORK...correct? I'm assuming I'm going to have to just stay on top …

Hello - so I got my EOB in the mail yesterday and I have been stewing ever since! First of all, I had a hernia repair and lapband together. The lapband was not covered by my insurance...according to the doctor's office...so I paid $5,500 of my own money and my insurance was going to cover the difference of $4,500 which was the hernia repair and anesthesia. I first had to have the procedure done to check for the hernia. The doctor's office billed $17,500 and my insurance paid $7,175. Next was the actual operation. The doctor's office billed $29,500 and my insurance paid $16,025. Now, according to the doctor, it only takes an additional 5 minutes to fix the herni…

Well the peer2peer didn't work & now they have denied my 1st appeal. I now have to write another appeal & send it to an external review company. This is crazy! I am getting so discouraged & feeling hopeless. But this is the surgery I feel is best for me so I guess I will keep fighting. Idk what else to do.

Hi! :-) I was curious if anybody has advice or similar situation. My BMI is 38. It's been over 35 for 5 years and has been documented by my primary doctor. To qualify through BCBS IL my BMI can be 35+ with 2 co-morbities. I was diagnosed with high blood pressure/hypertension and high cholesterol 3 years ago. I also know I have sleep apnea but have not had that documented on paper by a doctor (yet). I took medications to control bp & cholesterol for a year until I got pregnant. From the moment I got pregnant my blood pressure has been normal. No meds for almost 2 years. I've gained weight even but somehow pregnancy corrected this issue. weird, right? Anyw…

I took a new job and will be switching insurance on May 1 through my new employer. Will the new insurance cover my fills?! Anyone go through this before?

I keep reading posts on these boards about insurance, and the need to document the information I get from the insurance company. I just scared that they will deny me due to "pre-exisiting condition." Thursday, 11-02-06, 6:30pm, I called the toll-free number on the back of my husband's UHC insurance card. After pushing a few buttons to get through to customer service, I talked with a man named LeLand. I asked him this question (straight from the paperwork supplied to me by Dr. Curry): "I am inquiring about my policy benefits on surgical weight loss. Is surgery for morbid obesity a covered benefit? In particular, I'm inquiring about lap-band surgery.” LeLand: "Yes…

I have aetma and they do cover WLS. The problem now is I have sleep apenea, but it is really mild. Other than high cholesterol and history of DVTs, I have no other comorbidities. So we are going with BMI over 40. Well at my first visit, my BMI was 39.9 (I had of course been trying another diet). Today, my BMI was 40.1. My problem is around 2010, I was doing sugar busters and had lost 10-15 pounds. So when they got my medical records from my Primary Care doctor and my GYN, my BMI in 2010 is too low. They have told me they are going to submit my 2009 and 2011 weights and say they couldn't find documentation for 2010. Anyone else's doctors offices do this? My ins…

i have atena insurance they approved me and i think i have to pay half, i dont know how much half is but hopefully not that exspensive. does any one know how much aetna will pay. or how much does the band cost???

Just called my insurance and found out they have denied me for the second time! :( i have a bmi of 39 and must have a comorbitity. Well the first time they said there wasnt enough paperwork submitted by my pcp. This time i have yet to find out why until they send the letter in the mail but my drs office believes its because they think I'm too skinny and I'm only borderline comorbitity! They are going to do the Dr on Dr call next but i have a feeling I'm going to be denied across the board! So dissapointed and totally don't think its fair that insurance makes you take all these steps only to find out your not going to be covered! Ive been on this journey since mar2011!…

I was wondering if anyone has had to go through the Kaiser San Diego Options Program. I've gone to orientation, I've done the lab work and I've seen the doctor (Dr. Ray). The doctor told me I was approved for the option classes. Does anyone know how long before they contact you, and how long before the classes begin? I guess I'm just getting a tad bit impatient, I feel like I've been waiting for so long for this (WLS).

HELLO EVERYONE NEED SOME CLARITY ON PHYSICAL THERAPY EVAL.. I AM 2 MONTH OUT FROM BEING DONE WITH MY SIX MONTH DIET.. MY DR CALLED TELLING ME THE INSURANCE NOW NEEDS FOR ME TO DO AN PHYSICAL THERAPY EVAL.. WHY??? IM UNCLEAR ON WHY THAT IS NEEDED.. SO I FOUND A THERAPIST BUT NOW I NEED A REFERRAL , I HAVE A PPO PLAN.. REGARDLESS HE STILL NEEDS A REFERRAL. HAS ANYONE HAD THIS OR IS THIS A STALL BY THE INSURANCE.. I HAVE UHC.. THANKS IN ADVANCE

?? Need support.I have alot of? S

Ok so I got word today that my pcp faxed in my 1st appeal to highmark today!! So fingers crossed that they will approve it this time!! I am so ready to have this done already!!

Since I was denied by my insurance & my Surgeons peer to peer talk has yet to take place (hopefully tomorrow), I told the surgeons office today that I will not be having the band or bypass. I have gone through 7 months of hell and Im not choosing another alternative. So, looks like I may be working overtime soon. Self-Pay may be in my future. Are there many out there who have self-paid?

I am 36 and 230 pounds.I'm on blood pressure meds and need this surgery.I have been on diers since I was12. Ww about 32 times.my insurance is husky a. I go to the npractionor in am and the nutricionist and phycologist on Saturday. I have plenty of gym records ,we records.does anyone in CT know how I can expedite the process to go quicker.do I have to wait the six months if I have hi blood pressure.

After discussing with Tricare (prime via North region I have)..there is no 6 month wait. But my clinic said if they send all my paperwork for approval (after all my pre-ops are done) that if I do not have a 6 month history in my dr's paperwork, sometimes the request for surgery is denied. Those who have had surgery w/Tricare (prime), did you go to the doctor every month for 6 months in a row prior to wanting to do the lap band? I for one only went to the doctor when I was sick or needed refills on my motrin. Appreciate any responses at all. Tricare has told me to do all my requirements and have the clinic submit for approval (w/o the 6 month period). By the time I …

Anyone in CT ever self pay? Price?

Based on my current policy (highmark bcbs) it doesn't look like I'm going to get approved. They require the BMI of 50. I have a 46. I have no comorbidity. I am healthy with the exception of obesity, which is not enough for them. I have hit a wall. I am lost and don't know where to turn. I have fought for 6 months for this, and I'm afraid I have no more fight left in me. I will write my one appeal letter then walk away. Would you have the band? Or buy the next plane ticket to Mexico?

I have husky health insurance in ct, was wondering if they cover the lapband? Thanks!

I had surgery a year ago. Insurance covered it. However, I recently took a job with a new company that does NOT provide insurance. I am having to get my own policy but I am having trouble finding a company that will cover me because I had surgery. Does anyone know of any insurance that will cover me? They don't have to cover fills but, I NEED INSURANCE! Thanks!

So about 2 months into my journey, I submitted all the required paperwork to Cigna. They require a 6 month, monitored weightloss program within the past 5 years. I submitted my weight watchers paperwork from before my first pregnancy about 4 years ago, knowing it was highly unlikely they'd accept it. But, I thought there was no harm in trying, since my dr wrote a great letter about how she's been on this weight loss journey with me for years, and cited several weights, etc. Well, I was denied. My surgeon even had a peer-to-peer review with the insurance person, and couldn't convince him. The insurance guy said we had to have 6 months of dr supervised weight loss counsel…

I went to my seminar and had my pcp draft a referral to tricare. And the baratric office told me toady that tricare wants me to wait 6 months?? Anyone know about tricare?? Help??

With HIP insurance is it mandatory to loose weight to be approved? Is it a long process?

Hi all! New to the forum and while browsing i read some of you used medicare so i decided to call once again after previously being told NO. i also got the following link to find approved facilities: Bariatric Surgery she said BMI must be 35+ must have weight related illness such as asthma,diabetes,etc etc previously been unsuccesful at weightloss go to an approved facility i am so thrilled! i am attending the seminar next week at my approved hospital!!!:drool:

Hello~ I was banded a little over three years ago, and have since lost 150+ lbs. However, in the last 18 months I have stopped losing (which I still need to do) and have gradually gained some back (about 25lbs). I have always be ULTRA sensitive to my band, I have had to have all the liquids removed twice due to complications. One just happened three weeks ago, and since the liquid is out, to be honest I haven’t felt this good in over a year. This doesn't count all the multipy trips to the Dr. office after a fill to have some taken out cause I couldn't swallow liquid. I tend to swell anytime they mess with my band. This has led me to the thought of just having it rem…

I have BCBS of PA, managed by Independence Administrators, but precert authorization for surgery goes through Amerihealth Adminstrators? Any one have any experience with this? Doesn't seem that they want a whole lot of jumping through hoops.....

Did your insurance require you to have a 6 mos supervised diet? I have united health care through the railroad employees and my precert just got sent in for approval. I'm nervous I'm going to have to complete a 6mos diet and well I'm just not very patient right now I've been waiting so long that another 6 mos seems like an eternity. I just hope I het approved with out it!

I am located here in San Diego and my local MTF is Balboa. This is my story...my PCM is a civilian Dr. thru Scripps Clinic and I went to her on Sept 7th regarding the lap band so she submitted a referral to Tricare for me to see their surgeon who is also civilian for a consultation. Within a week Tricare Prime approved me to see the civilian surgeon for the consult. On October 23rd all my paperwork was submitted to Tricare for lap band surgery within 24 hrs I was approved with modifications. Meaning that I can have the procedure done but it has to be done at the MTF Balboa. My issue is...why did Tricare approve me to see an civilian surgeon for the consult when they kne…

So far I've talked to my PCP, got a referral, called my insurance to see what they required, and am going to a seminar tomorrow. I am scheduled to meet with my surgeon on Sept 6th. However, when I called the surgeons office the insurance woman there was in disbelief that tricare doesn't require a 6 month weight monitoring. Now granted I'm sure they dont get a lot of tricare patients because I live nowhere near a base. but anyhow. When I spoke with Tricare on the phone (and looked it up on their website) I was told that I have to be 100 lbs over weight (check) with one or more comorbidites (I've got THREE) and have a phsyc eval... Anyone with Tricare have to have the…

Yes, I went through 6 months of dr supervised nutrition classes, sleep study, psych eval, x-rays, blood work, etc. I'm glad that it took six months because during this time I became more knowledgeable of what I'm doing, why I'm doing this, what to expect, and to just feel much more comfortable with the entire process. I didn't want a quick approval process. I feel I'm more prepared and ready to undergo surgery, deal with the post-surgery issues and begin my new lifestyle. Good luck to everyone! Peg

Someone told me that the private pay portion of my surgery (the part insurance did not cover) is tax deductible, for calendar year 2012. Has anyone else heard this and do you know how it's done? My doctor also wrote me a prescription for a gym membership that he said should be deductible as well since it was prescribed. ???

I have carried a short term coverage for years that kicks in at day 8 after illness or injury. I've used it once for c-section. Called today to find out about coverage and was told if my Dr. wrote a dx code for illness/injury it would be covered. Don't see childbirth as "illness" so wondering if anyone has dealt with this. Consultation Friday so planning to ask Surgeon too....

Hey Everyone!! So, I have a minor dilemma. I have my consult on the 28th. I know that my surgeon will ask for pre op test like blood work, ekg U/S of my abdomen and EKG. That means I have to go to my PCP and request all of those. Well, she isn't very cooperative with anything I ask for. ( really really long story). Then I would have to go back to my surgeon for my pre Op appointment. Now, my question is, Do I need another referral to go back to my surgeon for my next appointment? On my referral paper it say it is for a consult only. But if my surgeon asks for all of these test and they all come back clear and he believes this surgery is medically nessacery do I h…

Approvvved after initial denial! I have wanted to put a post up like this for a while LOL March 8th..OMG lol

:banghead: Spent ALL day writing my appeal letter. They denied me because my BMI is not 50+. Carefirst...sooo behind the times. I kind of knew I would be denied at first anyways so I was really prepared with my guns already cocked :aureola: ..so hopefullyy with all the information I just threw in their face I will be getting my approval soon. LOL :Banane56:

Hello all Im new on here.. and what a way to start..tomorrow seeing my surgeon and submitting all my clearances to the insurance company.. I heard BC/BS Horizon of NJ is a hard one.. My BMI is 47.5.. and only have asthma..no other real co-morbities.. Ugh. the stress of this all..

I decided to tell my story about my fight with BCBS FEP (Federal Employee Program) to cover my sleeve in hopes that maybe it will help someone else. This process took over a YEAR. It was discouraging at times, but I was not going to give up. It’s a long read, but trust me, I shortened it as much as possible. The process started in September of 2010. I decided I was finally going to do something about my weight and I was looking into the lapband. My husband and I went to a weight loss seminar at one of the surgery centers in my area. During the seminar, the surgeon started talking about the Sleeve and I was immediately excited about it. The idea of having a fore…

Looking at my employee hand book, weight loss programs are not covered.....Duh! With that being said is the Lap Band procedure considered a "Weight Loss Program"?

More often than not, the people that I talk to have insurance coverage thru family members. What are the options for a single person who does not have health insurance? I desperately want to have bariatric surgery, and get my life and career moving in the right direction. Any ideas out there? Thank you so much.

I started looking at WLS last summer. I called my insurance repeatedly and NEVER did they say I would need to do a 6 mo supervised diet. Because of the "max out of pocket" on my insurance, I decided to wait until the beginning of the year so I could tend to a few other expenses with less out of pocket (infertility diagnostics). So, i spent most of January with my gyno and then went to meet with the surgeon for the sleeve on Feb 8. THinking I had all my ducks in a row based on the HOURS I spent on the phone with UMR/UHC (myinsurance), the surgeon's office contacts my insurance and they say I need to do the 6 month diet. Had I been told this by my insurance last summer…