ccarter8219

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

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

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?

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

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

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)

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

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.

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

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

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

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:

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

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