i am soon to be a former student. i have been in college and without usable health coverage for about ten years. i saw doctors intermittently, i havent had a PCP in about 13 years.

so, now i have a job like a real grown up and im getting benefits and i want to have lap band surgery. i have an aetna hmo in case that matters. my worry comes with all this talk of a 5 year history that is required. where on earth will i get that if i havent seen a doctor in like two years??? ive been obese since childhood, but hospitals arent really that great at keeping records are they?

so, what am i supposed to do when my obvious girth isnt enough?

granted i havent started the process yet, i havent even decided on a doctor (PCP nor surgeon) but i like to be able to plan, so i figured i would ask now. this forum is super helpful! thanks for reading!

I didn't have documented proof of weight loss attempt. My insurance/hospital had a weight loss program that I had been in for a few months and then quit and then decided to go through the six-month process. I don't know how stringent all insurance companies are on this issue. But it's safe to say you won't know until you start the process. Even if you have medical records documenting overweight issues going back, that might help. I think most of them are concerned that this is an ongoing issue and not just where you've gained weight recently. Most insurance companies are more concerned with the other issues...BMI, comorbidities...than anything. I was a low BMI patient and really had to jump through hoops but if you have a primary care physician that is in your corner it will definitely help. Even just contacting your insurance company and asking them what are all the requirements in order to get approval. In hindsight, if mine had not been approved, the cost has come down so much in other states I would have been paying cash in a heartbeat. My daughter had to pay for hers and went to Texas to one of the top surgeons in the US.

Good luck with your decision and the process.

Trisha

thanks so much, trisha! if i do have to pay out of pocket i will have to wait a few years....just getting out of school means that i dont have much in the way of savings, i dont have a 401k or a house to remortgage and i have like 100k in student loans i have to start paying off at some point....

I'm a firm believer in positive thinking. So just put it out there that your insurance company covers lapband and you will be approved. I even had to gain like 10 lbs. My insurance required that you lose 10 percent of your body weight in the six-month process. So I knew that I could really be borderline after losing 10 percent to still be in the BMI range. My primary care dr even told me to put rolls of quarters in my pockets. I even told them I was only 5-4 and they never questioned it. Anything I could do to be within the guidelines. Had the sleep study done for sleep apnea, which was really the only thing that got me approved.

So start the process and at least find out what your insurance company will and won't pay for. That will give you at least a starting point. Keeping my fingers crossed for you. But, had mine not approved, I would have been going out of state somewhere to self-pay. Mexico was an option but there are some states out west that it's almost as cheap as Mexico now.

My daughter paid 12k for her and luckily her local doctor agreed to do the follow-up/fills for her because she knew the surgeon who did the surgery.

Good luck!!

Trisha

Hi Maybe,

I wrote a post to you yesterday that went into web oblivion, or I forgot to hit the submit button. I prefer to think it went into oblivion! :biggrin:

Anyway. Let me try it again.

Look at it this way, if you have to wait to be self pay, you have to wait. If you have to wait to show the history of obesity, you have to wait. Either way, time is going to pass. Use the time wisely to educate yourself about this process. In the end, you'll get the surgery you need, and most likely the insurance will pay for it.

I don't know much about Aetna, I had BCBS. But I would not be surprised if you have to appeal. Don't be afraid of appealing, you owe it to yourself to fight for your health. Hey! There is a good motto for us!

My opinion is that they deny and deny and have all these hoops hoping that we will give up and they don't have to pay out the money for the surgery.

I was denied even a consult with a surgeon because I hadn't done a 6 month supervised program. I submitted years and years worth of Weight Watchers records and BCBS waived that requirement. After that, I had no problems with the insurance portion. I made a good argument, they agreed.

You could submit with the weight you had logged in 2007 (did they record that you were to heavy to weigh, or just that you did not weigh in?) and where you are now. If you were too high for the scale in 2007 and still roughly that high now, point out how unlikely it is that your BMI dropped to a healthy level in 2008, be sure to point out how many pounds that would have been to lose and regain in that span of time.

While perhaps not impossible to do, losing and regaining 200 lbs. in a year and a half or two would be less than healthy to say the least.

Sorry if I am overestimating on the amounts here. Not trying to be rude just trying to make a point.

I am of course using logic here, which the insurance companies don't seem to understand. But if you submit pictures of you from years past like when you were much younger showing obesity then list the few records you DO have--I believe that to be a long history of this disease.

The book Weight Loss Surgery for Dummies is an excellent resource. It has some great appeals letters.

Best Wishes,

Denise