ccarter8219

If it is an exclusion to your policy, then it would not cover the surgery as well as not covering the fills.

If you did not reveal this condition at the time of your application it could be considered a non-covered diagnosis/procedure. If this is a group insurance from your work and you did not have to reveal this information then it should not be a problem. However, most of the time if they did not cover the band they won't cover the fills. It will depend on whether your group covers Weight Loss Surgery for the Lap Band. Each group is different.

I work for one of the major insurance copany medical review units. Is this surgeon a participating physician with the TriCare insurance? If so, he cannot legally balance bill you for what TriCare does not pay as this is the amount he contractually agreed to accept. He can only bill you for co-pays and co-insurance amounts. If is is NOT participating with TriCare Insurance then you will have to cover any difference. Crystal

Hello, Lovenox is an anti-blood clotting injection you receive in your abdomen. It absorbs best in the abdominal tissue. It is not given to everyone. It depends on your surgeon.. It is also depends on your size and how well the surgeon feels you will move after surgery. Hope this helps, Crystal Carter RN

Yes, I had the doctors office submit everything. I just gave the doctor a list of all the diets I had tried and failed, and a list of my weight fluctuations over the last 5 years. I had the psych eval and the nutrition consult all done before the paperwork was submitted. hope that helps. Good luck!!:thumbdown:

Here is the information sent to me by BCBS of GA (Wellpoint) which is associated with Anthem BC. Gastric bypass and gastric restrictive procedures with a Roux-en-Y procedure up to 150 cm, laparoscopic adjustable gastric banding (for example the Lap-Band® System or the REALIZE™ Adjustable Gastric Band), vertical banded gastroplasty, or biliopancreatic bypass with duodenal switch as a single surgery, is considered medically necessary for the treatment of clinically severe obesity for selected adults (18 years and older) who meet ALL the following criteria: BMI of 40 or greater, or BMI of 35 or greater with co-morbid conditions including, but not limited to, life threatening cardio-pulmonary problems (severe sleep apnea, Pickwickian syndrome and obesity related cardiomyopathy), diabetes mellitus, cardiovascular disease or hypertension; AND The patient must have actively participated in non-surgical methods of weight reduction; these efforts must be fully appraised by the physician requesting authorization for surgery; AND The physician requesting authorization for the surgery must confirm the following: The patient's psychiatric profile is such that the patient is able to understand, tolerate and comply with all phases of care and is committed to long-term follow-up requirements; and The patient's post-operative expectations have been addressed; and The patient has undergone a preoperative medical consultation and is felt to be an acceptable surgical candidate; and The patient has undergone a preoperative mental health assessment and is felt to be an acceptable candidate; and The patient has received a thorough explanation of the risks, benefits, and uncertainties of the procedure; and The patient's treatment plan includes pre- and post-operative dietary evaluations and nutritional counseling; and The patient's treatment plan includes counseling regarding exercise, psychological issues and the availability of supportive resources when needed. :cursing: Hope this helps. Crystal

PPO does stand for preferred provider organization, and I believe it depends on which state your BC/BS is a member of to which guideline is utilized. Each state has their own guideline. I work for the BC/BS of GA which is called Wellpoint, and it includes several of the states such as CA, NY, VA, OH, NC. I think there are more, but I cannot remember all of them. We are combining to an enterprise wide name of Anthem Blue Cross. Most states follow the 30-31 day rule for an answer to be completed on a request for precertification/prior approval/pre-determination. However it may be delayed if they ask the provider to submit additional information. Hope this helps.

Dry Swallowing is just swallowing air without food or drink. :confused: Crystal

I would find out from the coordinator why they stated I was "good to go" when I needed the 6mo diet. If the insurance company has approved the surgery without the 6mo diet, then by the majority of the state laws say they cannot take back what they have already approved.

Welcome to the site!!!:thumbup: There is a lot of information that as an successful bandster that you may be able to help with, and if you have questions / issues the others may be able to help you.

I can agree to disagree. However cheating on a diet is not the same as leagally lying to your insurance company. You have no contract with your doctor to eat what they tell you, it is your on conscious. And by the way, the newspaper companies also lie to gain a profit. They spread gossip and rumors. No one ever knows the whole story, they just give you what they think you need to know. I agree that it is sad that children cannot get experimental drugs depending on their policy, but the policies are for their own benefit. How do we know that the "experimental" drugs won't kill them sooner. If we pay for it then they will sue the insurance company because we paid for it. Insurance companies are damned if they do and damned if they don't.:crying: Crystal

I am sorry you feel that way. No matter what you say, it is still fraud. I am one of those "medidal personnel" you think receives bonuses for justifying denials, however we are people of integrity and follow the guidelines. The Physicians always do a second review if we cannot approve a request. The nurses never give denials unless it is a contract exclusion. BCBS does not have to allow for WLS. It use to be an exclusion to all policies. I too was approved with a low bmi, but I had the appropriate co-morbidities. If don't begrudge anyone who meets the criteria to have WLS, but if you don't meet then you don't meet.

They can request all of your medical records from all of your providers to verify the actual information. If they have any inkling of suspicion they will demand a full refund and file charges. Just because you got approved for a procedure does not guarantee payment. It is just a certification of medical necessity. You can justify it all you want but it is still illegal. If you don't answer to it now in this lifetime, you will have to answer to the higher authority. Thou shalt not steal, and lying to get an approval is stealing. crystal carter rn

This is insurance fraud!!!!!!!!!!!!! :crying: If you get caught you face not only fines but imprisonment. I work for an insurance company and it is looked at very closely. It may not bite you when you get it approved, but the company can audit your case and take away any money it paid and press charges for insurance fraud. Crystal Carter, RN

thank! I have heard of the Rotary Club, but I had never heard them called Rotarians.

I'm sorry, but what is a rotarian? Crystal

I have to agree that everyone need realistic expectations. Also, you want your skin to tone up as you are losing. If you loose too fast, your skin does not have time to adjust. Crystal :thumbup:

I know it is easy for us to be in a hurry for the weight loss to occur, but slow and steady wins the race. Remain positive and everthing will turn out perfectly. Have faith in yourself and your ability to work with your band. Remember your band is just a tool to assist you with your weight loss. I too am still fighting with the need to lose weight faster, but when I think of my overall outlook on how much better I feel, it makes it worth the while. Keep up the good work! Crystal Carter, RN

What exactly is the definition of Onederland? :cursing: I am sure I am being silly. Is it pronounced like wonderland? thanks, Crystal

Be patient. You seem to be right on track. :smile2: You are still in your healing process. Average weight loss once healing has been completed is 1-2 pounds per week. You don't want to lose it too quick because it won't give you skin time to adjust. Also, it is hard on your kidneys, and you are more likely to loose your hair when you lose too much weight too quickly. Crystal Carter, RN .

Unless they updated it, I couldn't find onderland on that one. Crystal

Thanks! Everyone kept using it then I was not sure what exactly it meant.

To find out whether or not it is a covered benefit or an exclusion, you can call the customer service number on the back of the card. Let them know you are interested in Lap-Band WLS, and they will tell you if it is included or excluded. PPO coverage seems to be better than HMO, but you can never tell. I am not sure about cigna, you would have to call their customer service number to see if it is or is not eligible (just like blue cross). You would need to know what group he is looking to join when he takes his new job. I hope all works out. Let me know if you have any other questions. Crystal Carter, RN:biggrin:

Hello, I am a review nurse for an insurance company. I have a couple of questions for you. 1 - What type of coverage do you have (HMO, PPO, etc.) & 2 - Does your group have an exclusion for WLS? If your group has an exclusion then they are rarely approved on an appeal. If your group is a self funded group, you can sometimes appeal to the group administrator to have the exclusion lifted. Let me know if you have any questions. I hope I can help. Crystal Carter, RN:rolleyes2:

I live in Lanett, Alabama however I cam up to Chattanooga, TN to have my Lap band surgery by Dr. Robert Sass at Memorial Hospital on 6/9/08 and have lost 28 pounds. :tt2: