ccarter8219

Hey Long! I have lost 76 pounds since my banding on June 9th, 2008. I hope all is well with you.

Crystal

I have United Healthcare EPO choice

Go to the following link:

www.unitedhealthcareonline.com

then choose:

tools & resources - Policies & Procedures.

Then choose:

Medical Policies ( on right side of screen under Policies)

then read & agree with their terms and conditions.

then choose:

Bariatric surgery.

This should give you all the info you need.

Coverage Rationale

Gastric bypass (Roux-en-Y; gastrojejunal anastomosis), vertical banded gastroplasty (gastric banding; gastric stapling), adjustable gastric banding (laparoscopic adjustable silicone gastric banding), biliopancreatic bypass (Scopinaro procedure), biliopancreatic diversion with duodenal switch, and laparoscopic bariatric surgery are proven in adults for the treatment of clinically severe obesity as defined by the National Heart Lung and Blood Institute (NHLBI) who are:

1. Morbidly obese (BMI of 40 or greater)

2. Severely obese (BMI 35-39.9) with at least one of the following obesity related comorbidities

Cardiovascular disease including stroke, myocardial infarction, stable or unstable angina pectoris, coronary artery bypass or other procedures

Hyperlipidemia uncontrolled by pharmacotherapy

Type 2 diabetes uncontrolled by pharmacotherapy

Hypertension uncontrolled by pharmacotherapy

Moderate to severe sleep apnea with a respiratory disturbance index (RDI) of 16 to 30 (moderate) or apnea-hypopnea index (AHI) >30 (severe) as documented through the completion of a laboratory based polysomnography.

This is just a small amount of their information. If you live in maryland they have specific criteria just for them.

You can e-mail me if you have any questions. my e-mail address is ccarter8219@live.com

Ok, I went to an information seminar, met with the patient advocate and she told me that I was covered and proceeded to tell what the requirements were, BMI of 40, 5 year weight history at a BMI of 40 or a BMI of 35-39 with 2 comorbid conditions. I ciouldn't believe this is what my insurance would ask for so, I called them. I spoke to a representative and they told me that I only needed a BMI of 40+ or 35-39 with one or more co morbid conditions. The advocate said that "the insurance" people that work for true results know a lot about insurance and they know what the requirements are. She told me to get the info, in writing and she would look over it. So, I called my HR dept. and retrieved a copy of the "Booklet of Certificate" which explains all of the coverage that my insurance company covers. In a nutshell it states that charges are covered if a person is severe or morbidly obese, and then it give the definitions of what those are. There is no mention of additional requirements. Is this correct??? If there are requirements where would I find them???

HELP!!!:thumbup:

The requirements are not always posted in your certificate booklet. Call your insurance company and ask them to mail you a copy of the requirements. What insurance company do you have?

Well... I just got off the phone w/ my insurance company (UHC). Of course, the policy that my employer bought does NOT cover any sort of weightloss procedures/plans (surgical and non-surgical). The Customer Care Rep told me to write an appeal letter and that I would have an answer from UHC within 30 days of them receiving my letter. Has anyone else had to write an appeal letter to UHC? If so, what was their decision for you? What type of info did you include in your appeal letter? Did you have your dr. write an appeal letter as well? THANKS!

Usually if the employer does not cover WLS there is usually no option for an appeal.

As you know there are always an exception to any rule :smile2:.

The exception to this rule would be that usually when a group is self insured through an insurance company. The employer can adjust the benefits as they want see fit as its their money.

When a group is self insured, it usally means they are using their own company money but the insurance companies administers the benefits & pays the claim out of the employers money.

Hope this helps, Crystal

I think what the poster is trying to say is that the hernia is causing a "lap band" sensation. That was what I understood.

Is this correct?

Crystal

I have Humana. I am self insured. My surgery was approved after meeting all the qualifications BIM over 40, Psych exam, Dietitian and a 6 mo Dr. supervised diet. All of which took almost a year. I had my surgery performed on 9/15/08. Now the surgery has still not been paid for. About 5 days after surgery I was sent a letter that stated that due to a diagnosis code that was used. My medical history for the past 5 years was needed to validate the claim. In short after many many phone calls later. It comes down to the fact that I gained 50 lbs from the time I had originally taken out the insurance and the time the surgery was done. My BMI was lower when I took out the insurance as I am a yo yo dieter and as most can lose the weight for the short term but can not keep it off. They are now trying to deny the claim. The thing is if they had denied the surgery for that reason before it was done I could have understood that. But my weight from the start to end was no secret. They had all the info and all the records from my Dr. supervised diet to see what I had gained. So why now after a $28,000.00 bill would they try to deny it. If they wouldn't have approved the surgery in the first place I would not have had it done. As there is no way I can afford it. That is why I jumped thru hoops for so long to get it approved. I am so upset!!! Can they do this ? How can I fight this ? I could lose everything if they refuse to pay. I live paycheck to paycheck now and could lose my home if they start garnishing my wages. Any info would be much appreciated. Thanks and sorry so long :yikes:

Did they give you an approval letter prior to the surgery? If they did, they should honor the approval letter.

Crystal

I never got that far.....the surgeon's office called me and told me Anthem will only cover $7500, and if they bill it through the insurance it will be $32,000 and that I could end up with $20,000 or more out of pocket. Then they told me I should just self-pay the $13,000 and do it that way ---There's no way I can come up with that right now (yeah, I've got $13,000 just laying around...NOT!). I am totally bummed! :ohmy:

They DID say it should be no problem to get the approval from my insurance though (even though it will do me no good). So I just got $1300 worth of lab work done for nothing!

I guess I'm gonna have to try to lose the weight on my own once again. :laugh: I cried at first, but now I am resolved to it and trying to keep a positive outlook and stay motivated. After spending Christmas with my mom and seeing what years of being overweight has done to her body, I know I need to get this weight off before it destroys me too. Wish me luck.

To all those out there who have insurance companies that will cover the real cost of the surgery, you are VERY lucky, and I wish you all the best.

Is your provider participating in the BlueCross Network? If so they cannot balance bill you for the difference. They sign a contract with BlueCross/Anthem that they will accept what insurance pays. You should only be responsible for your deductible and any co-pay / co-insurance.

Crystal (Nurse Reviewer for an insurance company)

Thank you guys so much for the replys and suggestions. I think perhaps I am on the verge of becoming obsessed about this whole thing. I am now having dreams about it! LOL... hmm.. wonder if that's a good thing or a bad thing. At any rate, I have to do something. Ya know, sometimes I wish the insurance people who had the fate of my health in their hands could spend a day going through what I/we do. I am absolutely certain they would approve any and everyone on the spot. I even suspect they may OFFER the surgery!!! I think my next step is to maybe call the insurance and explain to them my situations. My only problem is will they actually take time to LISTEN to me, rather than just hear me. Thanks again!!

Best of Luck!

Speaking as an insurance company nurse reviewer, most of us either have been there or are there, but it is not up to us to make those decisions. We have a guideline to follow and if it does not meet the guideline we are required to send it to the medical director to make a final decision.

If it was up to us we would probably cover anything and everything, but then insurance premiums would be so high no one would be able to afford it.

If we ignore the guidelines and approve things that do not meed the criteria, then we would lose our jobs.

Crystal

Jaundice is the yellowish staining of the skin and sclerae (the whites of the eyes) that is caused by high levels in blood of the chemical bilirubin.

The whites of your eyes are yellow because your liver is having a hard time filtering your blood. This is called Jaundice. Please contact your doctor and let them know about your situation. They may want you to come in for some blood tests to make sure your liver is functioning correctly.

Crystal Carter

Hey, I had my surgery on June 9th as well. I have lost 65 pounds as of Dec 29th. It is truly a life changing surgery. I am now able to do the things my kids always wanted to do. Like go for a hike, and ride bicycles. :party:

Life is not a piece of cake, I still have to work hard, eat the right food choices and drink enough Water. But is is so worth it.

Crystal

Down here in Columbus, GA it is not honored by Ryan's or Golden Corral. :biggrin: I have had it honored at IHOP.

Crystal

I had Lap band 1/5/08. The day of surgery i weighed in at 367lbs. As of this morning i am weighing in at 239lbs. Lost 130lbs so far and still losing. I am concerned with a few things though. One i have never gavr up my habit of drinking. I drink about a half gallon of Whiskey every week. I know many of you will say i have a problem but i dont i just like to drink. I drink about a 5th every Friday and another 5th on Saturday. Im only 23 so cut me some slack. The other problem is that i have recently been taking Adderall during the day for school and at night i take about 2mg Xanax to calm down after i work out. I dont mix pills with alcohol either. I am wondering if this can increase my risk of erosion. Is adderall/xanax/Hard alcohol anything like NASIDs. I am having no problems other than i get a funny pain near the port area every no and again almost like a tug. Simply wondering if i need to stop taking my meds. Are they going to increase my risk of band removal. If so ill stop immediatly. I will never have this thing removed it has completely changed my life. I can ride on an Airplane, tie my shoes easily, sleep 5 hours and feel great rather than sleep 12 an still fell tired. I can run, lift weights, and dont even get me started on the ladies; didnt have a sex life before the band, i have made up for that. Went from taking, Lexapro,Diovan,Nexium,Water pill,Toprol to nothing. Well until recently the xanax and adderall. Had obstructive sleep apnea; dont even own my machine now. If you are considering this procedure do it dont wait like i did just do it. The best 13 grand i have ever spent. If anyone has any advice on my condition let me know. I am not going to take another pill until i get some answers. Thanks to all fellow bandsters.

Jeremy, Alcohol (hard Liquor or beer) alone will erode your esophagus and stomach lining without the lap band. :eek: Having the lap-band only makes it twice as bad because it sits in your pouch before going down. I am a nurse and have seen people who drink 1 beer a day and state they are not alcoholics but it did not keep them from dying from erosion of the esophagus and intestinal bleeding. Please be careful and don't take any chance of harming yourself. You may only be 23 but you do want to live to see 24.

God bless and take care.

First and foremost, if you are a republican (as I consider myself), we HAVE no party. I can only speak for myself when I say that nobody has represented me in a very long time. The closest they have come is Sarah Palin, but sadly she's only running second fiddle.

And it IS my money. If they are taking it from me to pool with money from others to pay to study the mating habits of bottle-nosed gnats, they are wasting MY money. If it's not my money, then they don't NEED my money. Let ME keep it and use it as I see fit.

As for supporting my fellow American, I am not obligated to do any such thing. I have no problem with supporting those who truly NEED. The problem, however, is that need has expanded very much like our own stomachs have, becoming something so overbloated and grotesque as to not even be recognizable anymore. I am not my brother's keeper unless I choose to be. The way I take that comment of yours indicates socialism, unless I am missing something. Too many people are crying "poor mouth," and our greedy government is all too willing to label them as such in order to get them on the government teat.

I am numb towards my duty anymore. I have a government that squanders MY money (and I will cry MY money until I die or the cows come home because it IS my money), and I have lowlifes who believe that if I make even a dollar more than they do, I must split it with them. I owe them NOTHING.

I am a huge believer in personal responsibility. Barring very few circumstances, if you buy more than you can afford, too bad, so sad. I will NOT bail you out. If you sign on for a mortgage for twice the house you can really afford, too bad, so sad, sucks to be you. I will NOT bail you out.

I am a responsible citizen, and I get crapped on everywhere I turn, bailing out this lowlife and that lowlife who wasn't responsible or was simply downright greedy. What about those of us who do the RIGHT thing? We constantly get punished for that and nobody gives a crap -- they just demand more of MY money. I say no more.

Here Here!!!!! Well said! :rolleyes2:

That fee probably is included in your price. I think that the reason we get charged an extra fee is they don't actually get all of the money that they bill insurance. This is a way for him to collect some money up front. Just my own personal opinion on that one. I can't see any other reason for it.

I too was going to be banded by Dr. Ponce's group, but the $1000 is a program fee (used to pay for their website, and their support group) they stated that they would not bill the insurance company as it is non-covered by the insurance company. I refused to pay it because I don't live in TN and would not be attending the support groups there. I live near Auburn, Alabama. I had surgery in TN becuase that is where my family lives.

I had surgery on June 9, 2008 by Dr. Robert Sass and felt that he was wonderful. He was very attentive and accessible. He is also a part of the Memorial Weight Management Center, but he did not charge any program fees.

Sometimes it is a safety issue. When you have surgery, they may use a cautery machine and if you are wearing anything metallic it can cause a spark to jump from the surgery site to other areas on the body. :biggrin:

I got a fill a week ago and it is tight. It is usually tight for the first week, but this time I can't eat anything. I can drink but I am starving and diabetic and having too many lows. I called the doctors office & I will get an unfill in the morning. I am on my period and I am wondering if this is the reason it seems so tight. I have 6cc in a 10cc realize band. Anyone else have problems with a fill during your cycle?

I always seem to be tighter during my cycle. It seems to be a hormonal issue.

Crystal

Ok so I have a few questions about tricare. They aren't completely for the surgery. I have a set of claims that were actually one day of bloodtests for my hypothyroidism...they were denied because

136 - SERVICES DENIED BECAUSE WE CANNOT DETERMINE PRIMARY INSURANCE PAYMENT. PLEASE PROVIDE EXPIRATION DATE OR COMPLETE PAYMENT INFORMATION.

I also had a bill from a visit with my doc for the same reason.

Then I have a few claims from my surgery that originally came up as paid..they are now listed as RETURNED.

Can anyone make any sense from this?

It sounds like your insurance company thinks you have other insurance that is primary. Do you have any other insurance? If not, then just call your insurance conpany to update your file to show you have no other insurance and they should adjust the claim.

Crystal

I think I am in information overload. And I realize everyone has different informaton from their doctor's, nutiritionist, etc. But in a quick read, what would you say are the things you MUST follow. I think these are important.

1. Protein, veggie, fruit, other

2. Must exercise but does anyone have some general guidelines. I am joining a gym tonight and I was thinking cardio 5 days a week and weights 3 out of those 5.

3. Chew, chew, chew your food and no drinking with food.< /p>

4. Snacking - not sure about this one. Is sf Jello, sf popsicles okay between meals or not.

Anyone else have input. I would appreciate it. Being a new bandster I want to do this right.

Thanks.

My doctor gave me a handout regarding the 10 important rules for lap band:

10 IMPORTANT RULES

1. Eat only 3 small meals a day, Breakfast within 1 hr of getting up and your last meal 3 hrs before you go to bed. (Skipping Breakfast is a bad idea; your body needs to have sufficient Protein. If you are tight in the mornings, try a shake, or yogurt.)

2. Eat slow & chew thoroughly, 15 – 20 times a bite.

3. Stop eating as soon as you feel full do not challenge the lapband, see how little you can eat and be satisfied. (It's even better if you eat until you're not hungry, don't eat until you get a full feeling. That might be too much.)

4. DO NOT drink while eating. (30 min before and 1 hr after) No carbonated drinks. Avoid gulping, sip.

5. Do not eat between meals. (Only rarely should you have healthy Snacks if you are getting hungry between meals. Or try a healthy liquid shake of some sort.)

6. Make good choices. Eat only good quality food. solid food is more important than liquid food. The lap band will have no effectt if you only consume liquids as it will pass right through. (Protein is especially important. If you don't consume enough protein, your body will actually store calories as fat. You need to eat to lose weight!)

7. Drink at least 6 – 8 glasses of Water a day.

8. Drink low calorie or zero calorie liquids.

9. Exercise daily You eat daily so you need to exercise daily.

10. Avoid doughy or sticky foods like white bread, pop corn, coconut, dried fruits as they can obstruct your band

hope this helps, Crystal :eek:

My part-time insurance will cover the surgery. i was talking about if I ever left.... would my state insurance cover the fills, etc. later on down the road. Out of pocket is not too expensive I found out.....for fills, etc.

I am not sure excatly what you mean. If your state insurance is the one that excludes WLS, then when you quit your part time federal job and that insurance ends, then the state insurance would not pick up if WLS was excluded as this probably would include the fills. You would need to contact your customer service for the state insurance to see if it would cover it.

thanks, Crystal

QUESTIONS... QUESTIONS...QUESTIONS....

Ok, I have Blue Cross Blue Shield through my full-time employer .....they do not cover the weight loss surgery at all.

I'm going back to my part-time federal employer who has Federal Blue Cross Blue Shield. They will cover the surgery and I plan on having it ASAP.

Once I have the surgery...and I get tired of working my part-time job a year later and decide to leave.

Would my Blue Cross Blue Shield from my other insurance cover the fills, etc.?

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

Hi Everyone! :laugh:

Just got banded (self pay) last Friday evening in TJ and feeling great!

I had a question that I was hoping someone might be able to help with.

Coincidentally, I am also fairly new to UHC (so might be considered a pre-existing condition?). What I was wondering was, if I went to my Doc. and/or insurance and said oh btw, I have this gastric band that you should probably be aware of.... Do you think they would cover check-ups or fills? I think my pcp would probably refer me to a nutritionalist because I am still no where near a goal weight lapband or not, but it sure would be great to have the fills covered too!

I've been reading here for quite some time and all the information posted has been invaluable!

Thanks! :smile2:

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 was approved by Tricare with no problems then the docs office called and told me that he charges $5000.00 for the surgery and insurance only pays $992.00 so he wants me to pay $4008.00????? I am insurance approved and now will not get my band because of this. I just cant believe it:mad2::smile2::mad2::wub::mad2::mad2::mad2::mad2::mad2:

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

what's a lovenox shot? I don't recall getting a shot in my belly before or after the surgery.

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

Thank you all for your comments!

Crystal:

I received the same information from them but I have a question for you.

This section:

1. 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;
   

What exactly did you submit to the insurance company for approval?

Also, you had your psych evaluation and surgeon evaluation before you sent in the paperwork? Did you or the surgeon's office send it in for you?

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:

Hello.

I have an Anthem BCBS of Ohio Preferred PPO.

They sent me information about what is covered and it comes down to the "medically necessary" issue. My weight puts me at a medically necessary level but my question is about Part 2 - previous attempts as weight loss and speaking with my doctor. :thumbdown:

Can anyone tell me what information they provided about previous weight loss attempts - Please? It does not mention anything about a time frame but wanted to know if they were verbally told one.

THANKS FOR YOUR HELP!

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:

1. 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
   
2. 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
   
3. 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