sarcar

Congrat on having your surgery tomorrow. I've not had this surgery yet, but I remember when I had my Gall Bladder out. It wasn't as bad as I thought and anesthesia was real easy for me. Once I came out, I sat an read until my signifant other got of work. They are a nurse at the surgery facility. Piece of cake and I'm sure you will do great.

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.

Sandy, I'm not sure unless you are self-funded that the employer can eliminate this surgery. When you purchase an insurance plan, the employee usually doesn't dictate what they will or will not pay. If it is a self-funded plan and just handled through TPA to make sure that the checks are paid and you are getting all the certification you need before surgery, then that is a different store. My insurance covers it but I had to jump through hoops (without my employer) to get this done. Others may have more experience with this - but continue checking and the first question I would ask your employer is if you are self funded. That will tell you a lot. Carolyn

I was originally and several times denied because "not medically necessary". This is a catch-all phrase. The first time is because they couldn't find all the previous diets in the upteen hundred pages sent to them. The next time was because they wanted me to do a 3-month diet that I would be on after the surgery. That was documented and sent to the insurance company and they denied "not medically necessary" because in Texas a PA has the same signature rights as a MD. They won't accept a PA's signature and the doctor's office had to resend with the nutritionist, PA and MD signatures. They said they would approve once they got the letter with this signature. Nope - not medically necessary. The doctor appealed and yesterday after 30-long days waiting on the appeal it finally got approved. All of the reasons denied said "not medically necessary" but I have found out that if you push the right people at the insurance, you will get the true reason it was denied. Many times it is just that they don't have all the information. Other times, they want you to do more dieting and proving. And then they also want to weed out those that think this is a quick fix and aren't willing to push hard for this. If you give up - they win. I've heard of people taking a year or more to get approved while some got approved the first time. I had to jump through a lot of hoops, but after six months, mine got approved. Keep up the chin and don't let them get to you. It is a VERY emotional ride.

Well my insurance says they pay for the morbidly obese to have lap band but I'm beginning to wonder. They first said all I had to do was go on a 3-month diet that I would be on after the surgery. I did and we covered all the basis - nutritionist and md supervised. So they sent in the letter but the PA signed for it because Texas accepts PA in the same manner that it accepts MDs. That was denied and they told the doctor's it had to have the MD signature. The person told the surgeons staff that if they get the letter with the nutritionist, pa and md signature it would be approved. Wrong - denied not medically necessary. Does anybody have a well written appeal letter? Nobody will tell us why it is not medically necessary and I have met 100% of the the qualifications that they sent me. So I'm not sure what their deal is but I need to appeal and I want to make sure I do this right the first time around. Carolyn

I emailed them and got a reply about three weeks later. Costs are $450 for one appeal and unlimited $850 and rush is and additional $300 and only available on the $850. They take about 30 days to process your paperwork. Rush is within 3 days I think. But have not used them yet. Still waiting to see if I am going t to have to appeal. Still waiting Carolyn

I've been fighting with the Insurance company (First Health) since March. They originally sent a list of criteria that I met. Then they came back and now say I have to go on the diet I will be on after the surgery for three months. According to my doctor, it looks like several insurance companies are going that way....so be prepared. I've met the first list of criteria, so after I do this diet for three months, I hope to be approved and on my way to losing. Carolyn

I started this new eating the way you will after the diet in early June. I just went in and weighed yesterday for the first time and they are telling me that August will be last time I have to come in weigh. I also am working with a Private Workout plan designed by Cooper Institute. I'm hoping this is the last of it (I wish I wish). So I will have to come back in early August for my final weigh in. Your PCP should be able to help you through this. What state is your First Health through?

Mine originally said that I had to be on a diet for at least six months out of the last two years that was doctor supervised. Now they are adding three months on the diet you will be on after the surgery. This 3-months has to be within the last 6-months. This 3-month diet also has to be dietician and doctor supervised.

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 to do this surgery this summer and get on with my life. Carolyn

Thanks all - this makes me feel better. Does anybody know what I am suppose to accomplish on this diet. I can succeed for 3 months in losing weight but not continue to be successful and gain it all back plus later. Do they want to see weight loss, no weight loss, partial loss????? I know I over analyze but I just want to make sure I give them what they want to see.

The insurance verbally told me that the only thing lacking was the 3-month diet in the last 6-months. Today, I received a letter flat out denying because it is not medically necessary. I am over 100 pounds overweight with high blood pressure. Diabetes & Heart Trouble runs on both sides of my family. What do they really want? I don't know where to go. Carolyn

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 what the goal of this additional weight loss program is? Am I suppose to succeed at losing weight for which we can all lose weight if you take away the food, but I just can't keep it off for extended periods of time. I want to make sure that I succeed at what they are looking for so I can get on with the surgery and my life changed. Carolyn

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?

It has to be a doctor, a nutritionist won't work.

Thanks to everyone who posted on this thread. I hadn't thought of being like the food police for her--I don't think that would have occurred to me that she might perceive it in that light. I can TOTALLY relate, as my mom was the "f.p." all of my growing up years, and how I felt about it. Thanks for that perspective. We are already practicing eating slowly, putting the fork down, looking around, having conversation. . . . . it's hard for me (but better for me too!) as I am a nurse and have only 30 min. for lunch everyday, and that includes heating your food, washing your dishes and going to the loo afterwards, so you get into the habit of eating really quickly, and not noticing what you're eating sometimes! Best wishes to everyone on the downward journey! Sara

3 bites of Atkins CheesecakeOkay now I have to know - where do you get this great tasting cheesecake? Is it already made in the freezer at the grocer or is it a mix?

I have First Health. The doctor thinks that there is, in fact, enough documentation to cover this requirement. So now all I need to do is to get a Psychological evaluation by an independent licensed psychologist or psychiatrist not affiliated with the surgical group.

Well, I got a reply back from the nurse that worked with my doctor and works with the doctor in the office that I transferred to. She said that there are records showing weight loss, dieting, exercise for several years back. She has had to write these letters before and believes there is enough documentation of weight loss/gain/loss/etc. showing that I have been attempting this for many years now. Hopefully this will get me past that point and then to the psych evaluation from a non-surgery center. Wish me luck.

She is young - just retired to have a baby. Her nurse still works at the practice and keeps in touch with her. I have a call into her. Thanks...

What is it that the insurance company is looking for. That you can stay on a diet for 6 months, that you can lose and then gain back, that you can't lose even on a diet, that you're dedicated to loosing?????

Hi, I've been reading for a few weeks now but still considered new compared to many of you here. It is real inspiring to read about all the success and it is also great to see all the challenges and how you conquered them. I'm from Dallas and am just waiting to get insurance approval. My insurance says they will pay for morbid obese so I think that qualifies me since I have a BMI of 43.5. Been doing research for about one year now and can't wait to get banded.

I have been doing research for almost a year. I now have the paperwork in to the insurance company so I am just waiting for approval. Question on returning to work. I work in an office so it is easy work. How long before I will probably be able to go back to work? I had my gallbladder surgery on a Friday afternoon and went back on Monday. Any luck it will work the same way or close?

Baylor has one of the highest rated Weight Loss Programs in the US (and probably world). The six doctors there have done over 3500 surgeries. They have one of the lowest risk rates in the US due to their extensive program. I have used Dr. McCarty for gallbladder surgery and really liked him. My SO is a nurse and speaks highly of Dr. McCarty, Dr. Kuhne, Dr. Arnold, Dr. Nicholson. So any of those would be highly recommended.

Baylor has one on March 10. My SO is a nurse at Baylor and the doctor's on their program are excellant. Already had Gall Bladder surgery through Dr. McCarty. Loved him and will have the lapband through him also.