Hi All

I am seriously considering lap band surgery. I have struggled with weight 20 of my 28 years on this earth. I am scheduled for my first appointment in 2 weeks. I am a little nervous that my insurance won't cover it as my BMI is right at 40.6 and I don't have any current health issues. I am considering self pay if they don't cover it. Does anyone have advice on the self pay route? I live in new york city and would appreciate any feed back on the surgeons here in the city.

Take Care

Petunia!

You can always call your insurance to see if they cover the surgery. With a BMI of 40 you don't need to have any co-morbid issues. I'm from North Jersey and my Doctor is out of Mountainside hospital in Montclair, NJ.

every insurance is different. Mine for example didn't require 6 months of diet before hand. Definitly check with your insurance first or go to the seminar about the surgery and let the nurses help you. My nurses were very knowledgable about which insurances expect what and if they didn't know the can call them and do the communication for you.

Thank you for the advice!

My insurance (Blue Cross Blue Shield of Texas) specifically EXCLUDES weight loss surgery, even if it were to save my life. I've heard SOME people that have BCBS get it covered, but I've had it checked 4 times now, and it is still excluded on our policy....gotta love my husband's policy thru work!!!

So, I am a self-pay. Getting the surgery done instead of trading up for a better mommy-van.....

I too was worried that I wasn't "heavy" enough and that the doctor's office would deny me, but NOPE!!! If your BMI is low enough to still be considered obese, then most doctors will consider you, especially if you're self-pay. They won't turn down guaranteed money....IMHO.

Good luck!! I don't live in NYC, but in Texas, so I can't offer advice as far as doctors. Keep us posted.

Hi All

I am seriously considering lap band surgery. I have struggled with weight 20 of my 28 years on this earth. I am scheduled for my first appointment in 2 weeks. I am a little nervous that my insurance won't cover it as my BMI is right at 40.6 and I don't have any current health issues. I am considering self pay if they don't cover it. Does anyone have advice on the self pay route? I live in new york city and would appreciate any feed back on the surgeons here in the city.

Take Care

Petunia!

I have BCBS Empire, they stated they would cover it in my first attempt to look into this surgery but at the time I was still too "light" to meet the required BMI.. In this case my height works against me! How much does the cost of the surgery run in Texas?

My insurance (Blue Cross Blue Shield of Texas) specifically EXCLUDES weight loss surgery, even if it were to save my life. I've heard SOME people that have BCBS get it covered, but I've had it checked 4 times now, and it is still excluded on our policy....gotta love my husband's policy thru work!!!

So, I am a self-pay. Getting the surgery done instead of trading up for a better mommy-van.....

I too was worried that I wasn't "heavy" enough and that the doctor's office would deny me, but NOPE!!! If your BMI is low enough to still be considered obese, then most doctors will consider you, especially if you're self-pay. They won't turn down guaranteed money....IMHO.

Good luck!! I don't live in NYC, but in Texas, so I can't offer advice as far as doctors. Keep us posted.

Most insurances at a BMI of 40 will approve. At 35 they require comoridities, but not at 40. I have United Healthcare and was approved with no comorbidities with BMI of 48. There is no harm in asking insurance questions. You may be surprised what they say. Good luck and keep us posted!

I am going through True Results in Houston, Texas, and their self-pay is $9900.00. During my individual consultation, they were able to perform many of the pre-qualification steps, like an office visit, stress test, etc. and I only had to pay my insurance fee of $50.00. Then I had to do a psych eval, and that was $65.00, since I still owed a little on my deductible..... I just finished my 2 sleep studies, and haven't gotten the bill for either of those yet, but I'm estimating my out of pocket total for those will be about $600, not including the cost of renting a CPAP machine, which I've been told I will be required to do, so add another $300.00 to that...

I think they said my fee for surgery also includes fills for the first year.....

So, all of the above, plus the Protein shakes, Vitamins, etc. mileage for driving all over town, will be around $12500.00........ IF insurance would have covered it, I think out of pocket would be about $3000.00.

Not exactly cheap, but if it will help me be healthier, live longer, and be happy with my own body, it's worth it.

I don't remember my BMI but i am 5 foot tall and weigh 222. Being banded will be my 6th surgery in 10 years....3 c-sections, 1 ear surgery, gall bladder removed........

Good luck!!! I go meet the surgeon Thursday, hoping for the best!!!

I have BCBS Empire, they stated they would cover it in my first attempt to look into this surgery but at the time I was still too "light" to meet the required BMI.. In this case my height works against me! How much does the cost of the surgery run in Texas?

Go to http://www.empireblue.com/ and enter your membership info. Then search your policy. It should state very plainly what is covered and what the requirements are for coverage.

Find out what YOUR coverage is, then worry about self pay if needed.

This is what I found..if it is your policy, a BMI of 40 or greater qualifies you. So don't lose any weight before seeing your surgeon. When measured, don't stand your tallest.

Best wishes.

http://www.empireblue.com/provider/noapplication/f2/s5/t9/pw_ad080419.pdf

Medically Necessary:

Gastric bypass with a Roux Y procedure up to 150 cm, laparoscopic adjustable gastric banding (the Lap-Band® System), 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 the following criteria:

Policy Statement

1.

2. 3.

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), severe diabetes mellitus, cardiovascular disease or hypertension.

*Note: Individuals considering the laparoscopic adjustable gastric banding (Lap-Band®) procedure must meet the above minimum BMI requirement and, in addition, have a maximum BMI of less than 50.

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. 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; • The patient’s post-operative expectations have been addressed; • The patient has undergone a preoperative medical consultation and is felt to be an acceptable surgical

candidate; • The patient has undergone a preoperative mental health assessment and is felt to be an acceptable

candidate; • The patient has received a thorough explanation of the risks, benefits, and uncertainties of the procedure; • The patient’s treatment plan includes pre- and post-operative dietary evaluations and nutritional counseling; • The patient’s treatment plan includes counseling regarding exercise, psychological issues and the

availability of supportive resources when needed.

Hi All

I am seriously considering lap band surgery. I have struggled with weight 20 of my 28 years on this earth. I am scheduled for my first appointment in 2 weeks. I am a little nervous that my insurance won't cover it as my BMI is right at 40.6 and I don't have any current health issues. I am considering self pay if they don't cover it. Does anyone have advice on the self pay route? I live in new york city and would appreciate any feed back on the surgeons here in the city.

Take Care

Petunia!

i know with ,my insu my bmi had to be over 40 and it was and i got the ok so i would go for it my day is in the morning and i cant wait so go for it i hope your ins will cover it for u and good luck

My gosh, your story is so familiar! I am 28, started putting on weight at age 8, my current BMI is 40.6. We are twins! I have Blue Cross Federal, and they are covering it. I had to do 3 months of supervised weightloss/nutritional counseling, etc. My surgery date is THursday, April 21. Good luck to you!

I don't know about your BMI of 40, but I live in NYC as well and I'm going through NYU medical center. Dr. George Fielding is going to be doing my surgery. I chose him because he himself has the band and I figured if any doctor could know the struggles, the ups and the downs, it would be a doctor who has had it.

you should definitely go to the seminar as they will give you all kinds of information regarding what they need from you and what to ask your insurance company. they also have someone in their office that will help you with the insurance stuff.

anyway, best of luck in whatever surgeon you choose.

My gosh, your story is so familiar! I am 28, started putting on weight at age 8, my current BMI is 40.6. We are twins! I have Blue Cross Federal, and they are covering it. I had to do 3 months of supervised weightloss/nutritional counseling, etc. My surgery date is THursday, April 21. Good luck to you!

How funny! Good luck with your surgery and keep me posted on your progress!

I logged in and tried to search for my policy but I am not having any luck. I put a question into them, so I should have an answer come tomorrow. Thank you for the advice

Go to http://www.empireblue.com/ and enter your membership info. Then search your policy. It should state very plainly what is covered and what the requirements are for coverage.

Find out what YOUR coverage is, then worry about self pay if needed.

This is what I found..if it is your policy, a BMI of 40 or greater qualifies you. So don't lose any weight before seeing your surgeon. When measured, don't stand your tallest.

Best wishes.

http://www.empireblu...pw_ad080419.pdf

Medically Necessary:

Gastric bypass with a Roux Y procedure up to 150 cm, laparoscopic adjustable gastric banding (the Lap-Band® System), 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 the following criteria:

Policy Statement

1.

2. 3.

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), severe diabetes mellitus, cardiovascular disease or hypertension.

*Note: Individuals considering the laparoscopic adjustable gastric banding (Lap-Band®) procedure must meet the above minimum BMI requirement and, in addition, have a maximum BMI of less than 50.

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. 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; • The patient's post-operative expectations have been addressed; • The patient has undergone a preoperative medical consultation and is felt to be an acceptable surgical

candidate; • The patient has undergone a preoperative mental health assessment and is felt to be an acceptable

candidate; • The patient has received a thorough explanation of the risks, benefits, and uncertainties of the procedure; • The patient's treatment plan includes pre- and post-operative dietary evaluations and nutritional counseling; • The patient's treatment plan includes counseling regarding exercise, psychological issues and the

availability of supportive resources when needed.

I am going through True Results in Houston, Texas, and their self-pay is $9900.00. During my individual consultation, they were able to perform many of the pre-qualification steps, like an office visit, stress test, etc. and I only had to pay my insurance fee of $50.00. Then I had to do a psych eval, and that was $65.00, since I still owed a little on my deductible..... I just finished my 2 sleep studies, and haven't gotten the bill for either of those yet, but I'm estimating my out of pocket total for those will be about $600, not including the cost of renting a CPAP machine, which I've been told I will be required to do, so add another $300.00 to that...

I think they said my fee for surgery also includes fills for the first year.....

So, all of the above, plus the Protein shakes, Vitamins, etc. mileage for driving all over town, will be around $12500.00........ IF insurance would have covered it, I think out of pocket would be about $3000.00.

Not exactly cheap, but if it will help me be healthier, live longer, and be happy with my own body, it's worth it.

I don't remember my BMI but i am 5 foot tall and weigh 222. Being banded will be my 6th surgery in 10 years....3 c-sections, 1 ear surgery, gall bladder removed........

Good luck!!! I go meet the surgeon Thursday, hoping for the best!!!

Why did they make you go through all the testing if you are self-pay? They told me if I paid instead of going through insurance it was 9900.00 flat fee and they could schedule me within 2 weeks. Just curious...I ended up going through insurance and using a hospital instead.

Petunia~ I would ask if you self-pay will they make you do all the testing? Then check with your insurance to make sure they will or will not cover and what testing you will need.