The Game of Insurance

Baron Patrick · November 1, 2005

Okay, this is the thing ....

My insurance - Cigna told me they do not cover gastric bypass, but they will cover the LapBand, BUT, (and the person on the phone made this emphatically clear), ONLY IF IT'S A MEDICAL NECESSITY.

Okay, if it wasn't a "medical necessity", I wouldn't be asking about it. Or, do they think I just want to have unnecessary surgery because they'll pay for it?

Soooo, I went to my doctor, who is NOT a supporter of weight loss surgery, and would not support me. Fine, I'm seeing another doctor later this month. I'm going to let this doctor know bluntly I'm having this surgery. You can support and help me with this, or I will find another doctor who will. I'm not playing games here. I'm 120 lbs. overweight, cant' sleep on my back, and my knees and ankles are beginning to feel the effects of the weight. I also injured my back in the military (many years ago) and receive a medical pension. They diagnosed me with degenerative arthritis so trying to exercise makes it a problem as well.

If the insurance will not cover this, then I'm going to the doctor for every lilttle thing I come up with - and it WILL be weight related. If they want to play the game, so will I. They are going to get so fed up with me - they will approve me just to get rid of me!

banded_for_life · November 1, 2005

You go Baron!!! Never, ever give up until you get what you want.

Time to love me · November 2, 2005

Great attitude! I hope it all works out for you, insurance companies, in my opinion, don't like to see people get healthy.. but they love our money.

Sandy3 · November 2, 2005

Baron:

You've got a fight on your hands alright! But it sounds like you're just the person who can do it!! Maybe you could find info on this site on Doctors in your area who are supportive of the surgery. That way you won't have to re-invent the wheel. Chances are if a surgeon knows that your insurance will cover the band, they will help you qualify. I've read on this site that some surgeon's offices do most of the work. I am going for a consultation at Barix Clinic in MI. today. They say they help you fight appeals. We'll see. I have letters from 3 physicians and a therapist recommending I have lap-band. My list of meds were so long I had to write two or three in the lines meant for only one. I am on 3 meds alone for heart and blood pressure, and have been for years. I have been getting ready to submit to the insurance for over a year: 6 months supervised diet, aquatic exercise program, psych eval AND counseling, referral to Nutritionist (as the 6 months of supervised dieting has had MIXED results..surprise...surprise). I hope I have most of my ducks in a row. Even with that I expect a denial. Surgery " for weight loss" is not covered under my policy...but it does not say they won't cover if "medically necessary". I am hoping that requesting the surgery to alleviate my medical conditions, not just to "lose weight" might work. Who knows? I am in for the fight too. I plan to appeal, appeal, appeal. One lady on one of the sites even wrote to the White House. Anybody got the President's address handy? Looks like Baron and I might be needing it. I wish you well Baron.

Sandy

Thinjen · November 2, 2005

You are right. It is a BIG game. I feel the same way that you do. I am currently seeing my doctor for 6 months...at their request. It's a catch 22. They will not pay for the visits, if it is labeled as obesity. However, I have to be seen for obesity. Unfortunately, I'm sick every month. I just can't seem to get healthy. It seems like I'm in my doctor's office every month. Seems ridiculous to have to get on the scale and talk about my diet just to be seen about a sinus infection. I hope I'm not sick at the end of this month...like I have been at the end of the last four months. What's a girl to do?