Anyone Self Pay For Lapband Who Is Trying To Get It Removed With Insurance?

[JaxBandster 11]

I got my lapband almost exactly five years ago. I was self pay so did not need to jump through the insurance hoops to prove that it was medically necessary for me to have it although I could have if I had insurance at the time. I wasn't employed but I had come into some money so I could afford to do it self pay. A wonderful thing so I thought at the time.

Now my lapband has eroded and I need to have it removed but my insurance is giving me the run around trying to say that I got it for "cosmetic" reasons. I guess if an insurance company doesn't give their blessing that it is medically necessary then they assume that it wasn't.

Anyway, I was just wondering if anyone had experienced this before and what the outcome was. I'm terrified that my insurance company isn't going to cover the removal of my band much less the revision surgery to the gastric sleeve that I want just because I was original self pay.

Thanks for any input anyone can provide.

[auntbrat 1]

I'm sorry you're having problems with the band. I also was a self pay because my insurance at the time didn't cover bariatric surgery.

My current insurance agreed to pay to have band removed. I was thrilled at the time. I didn't want it removed until I had approval on bypass. My insurance denied removing band and converting to bypass surgery. They said unless I have a mechanical failure with the band they won't convert it. I am still so frustrated. I meet all of the criteria for bypass and they still won't do it.

I would guess that you have a pretty good chance at getting coverage for it. I wish you the best.

[JaxBandster 11]

I'm sorry you're having problems with the band. I also was a self pay because my insurance at the time didn't cover bariatric surgery.

My current insurance agreed to pay to have band removed. I was thrilled at the time. I didn't want it removed until I had approval on bypass. My insurance denied removing band and converting to bypass surgery. They said unless I have a mechanical failure with the band they won't convert it. I am still so frustrated. I meet all of the criteria for bypass and they still won't do it.

I would guess that you have a pretty good chance at getting coverage for it. I wish you the best.

Thank you for the reply, I'm sorry to hear that your insurance company wouldn't cover your surgery.

My insurance company's issue is that since I was self pay, they have no way of knowing if my band was medically necessary. I was 277 lbs at the time with a 40 BMI and sleep apnea. I would have qualified if I had gone through insurance but I didn't have to because I had the funds to pay cash due to an inheritance. The insurance company says if the surgery wasn't medically necessary that they would consider it to be cosmetic and they do not cover complications from cosmetic surgery even if those complications are life-threatening.

So as it turns out, I may have to prove medical necessity for a surgery that I had five years ago in order to get it reversed and then quite possibly, have to reprove medical necessity to get the revision to the sleeve. They're making me crazy!!!!!!

[DELETE THIS ACCOUNT! 12,703]

Granted I've not had this issue, but if your band has eroded it is now a medical issue, regardless of the reason it went in originally.

I would officially appeal it and be sure to include a letter from doctor stating why an eroded band IS a medical issue.

Quite frankly, it seems to me if they refuse to pay and something goes wrong in the meantime because of it, you could sue them. Might not hurt to point that out to them, either

[Cazzy 725]

Are you not able to get them your medical records from when you were banded ? granted 5 yrs ago is a long time but surely they keep medical records longer than that, the hospital where u were operated must have done some pre-surgery tests etc, just supply the insurance company with proof. In the UK this would be classed as a pre-existing medical condition for private medical insurance and they wouldnt touch it here even with proof !

[JaxBandster 11]

I am hoping that if I provide sufficient evidence that I met the medical necessity requirements originally that they will approve the removal. I may have to jump through all the hoops again to get approval for the revision but I'm ready to do what is necessary. My original surgeon should still have all the documentation and now that I think about it, I might have something here at the house as well. Going to go look.

I posted the images of my endoscopy on another forum. Not sure they will allow them here as they are quite graphic and the pro banders might get upset with me. I can guarantee that if anyone considering getting a lap band were to see them they would have serious second thoughts.

[MichelleD 1]

I am so sorry to hear this. I am in the same spot as you are, I go in next Monday for an endoscopy, my Doc thinks mine may have eroded as well.

I was self-pay with my banding as well, and now that I am looking to get mine out I cannot get my insurance to cover it. Even if my band turns out to be eroded, I will have to pay for the de-banding.

Insurance basically said that they wont cover it being taken out because it was my choice to have the surgery in the first place.

I hope all the best for you and your surgery, I hope you are able to get the insurance to cover. If not, I know that in my case I will at least get a discount for paying up front.

[Jean McMillan 2,973]

Whether your insurance will pay depends on the terms of your particular policy. I know of quite a few bandsters (me included) whose corrective or revisional surgery was covered as a medical necessity regardless of whether the original band placement was covered.

Good luck!

Jean