Hello,

i live in southern california, i have Medi-Cal insurance (HealthNet, Mainstream Molina) i called my insurance and asked about bariatric/lap-band surgery coverage and was told they will pay for anything that is deemed medically necessary and referred by my doctor.

So i have my doctor's appointment next week and i am going to go over all my symptoms with him and hoping he will refer me to get the surgery.

- Does anyone have experience with similar situation?

- Do you have all the symptoms, but your doctor won't refer you to get the surgery?

- Is it easy for doctor to refer insurance to cover and get surgery done?

- In your experience, given my info below do you think i will get referred by my doctor?

about me:

36 years

5-10" / 370 lbs.

BMI= 53 (40+ considered morbid obese)

Symptoms:

Sweating with light movement (short walk, house cleaning, stairs, standing for long time)

Shortness of breath (walking up stairs in home, moving furniture around, walking over 20 yards)

Burning lower back pain (walking over 50 yards, house work)

Heart burn

Wheezing (sometimes)

Hyper Tension

thanks!

I had a bit of the same problem. My insurance would only cover it if it was medically necessary. At first they denied me, but after an appeal they excepted me. I was 24 and I was a diabetic weighing in at 474. I had shortness of breath and I stayed fatigued all of the time. I do not see why they wouldnt consider you.

Good luck.

Wanda

All doctor's are different honestly. When I lived in South Carolina a couple years ago, I inquired about Lap Band with my PCP (who I had seen since 1999), she was against it and there was no way she was going to recommend me for the surgery. She sometimes had a very old school approach to things, basically saying I could lose all the weight on my own.

I moved to Florida just over a year ago, and started my lap Band process this past December. This time I got the name of a PCP that they deal with all the time from my Lap Band surgeon. Getting her to write the letter of necessity was pretty easy once I was checked out and got Cardio clearance, Anesthesia clearance, and did a sleep study.

Basically long story short, it all depends if your doc is an advocate of Lap Band or if they have the attitude that you can lose your weight on your own.

List of Co-Morbidity for Lap Band:

• 
  Cardiometabolic syndrome
  
• 
  Type 2 diabetes
  
• 
  Hypertension
  
• 
  Dyslipidemia
  
• 
  Coronary heart disease
  
• 
  Osteoarthritis
  
• 
  Stroke
  
• 
  Gall bladder disease
  
• 
  Obstructive sleep apnea
  
• 
  Gastroesophageal reflux disease (GERD)
  
• 
  Some cancers (endometrial, breast, and colon)
  

Looks like you may qualify on the BMI alone and you also have Hyper Tension. Most insurances will cover lower BMI's (35 or below) if you have a least 1 co-morbidity, however, all insurance companies have different requirements.

I can share that at 325 lbs, before the band I had severe sweating and shortness of breath for any little activity. I was often embarrassed by this. Mild back pain, but, had excruciating knee and leg pain. I would walk to exercise but there was a price to pay each time. After the band and 120 lbs. lighter I sweat very little, no more knee pain. I jog 2.5 miles a day and feel great!!!

With my insurance company (BCBS of NM) my primary doctor's letter of necessity made all the difference. I was approved 3 days after it was submitted and of course after I had completed the 3 months nutritionist's requirements. Hope your primary is on board. Good luck. Jake

If your Dr does not give you the recommendation, I would find one who will.

Stephy is right! I would switch to s doc who is supportive and understands the lapband process! This sure is not "the easy way out"!!!

Good luck. The first thing that changed with some of my weight loss was decrease in the constant sweating and gasping for air.

Looks like you may qualify on the BMI alone and you also have Hyper Tension. Most insurances will cover lower BMI's (35 or below) if you have a least 1 co-morbidity, however, all insurance companies have different requirements.

I can share that at 325 lbs, before the band I had severe sweating and shortness of breath for any little activity. I was often embarrassed by this. Mild back pain, but, had excruciating knee and leg pain. I would walk to exercise but there was a price to pay each time. After the band and 120 lbs. lighter I sweat very little, no more knee pain. I jog 2.5 miles a day and feel great!!!

With my insurance company (BCBS of NM) my primary doctor's letter of necessity made all the difference. I was approved 3 days after it was submitted and of course after I had completed the 3 months nutritionist's requirements. Hope your primary is on board. Good luck. Jake

-------------------

This is exactly what im dealing with, ive tried to get as much movement as possible. but back and calfs flare up when pushing myself to go, makes me have to stop..not to mention out of breath..sweating heavy. my kids go to school bout 300 yards from house, and i cant make it there and back without multiple stops, when back im drenched! but in pain from it too. (thers also a 100 foot hill to climb bout 30% grade along the way)

i need the lap band to give me that guard of feeling full and helping to drop weight, once down a lil i know i will start walking ..eventually running to drop more.

plus i hear its best to exercise along the weight loss journey to prevent extra hanging skin i hear??

Please keep us posted on what your doctor's response is to the lapband. I highly encourage you to pursue the lapband or weight loss surgery. With the agonizing pain associated with being too heavy is a very difficult way of life, especially when you can't be as active with the kiddos as you wish you could be.

With all the dieting and yo yo weight loss all my life, I had to do something not only too lose the weight but to keep it off. The band has and is doing this for me. Man, it has changed my life and outlook! Feel free to ask any questions. I'm there for you. Jake

With healthnet they wanted me to Do a medically supervised weightloss plan for 6 months.I think weight watchers will do.

Water based exercise is great for those of us who are significantly over weight. If I can go infront of the high school swim team that practices at my gym wearing a swim suit at 365 pounds anyone can!

All joking aside swimming (I use a snorkle makes breathing easier) and water aerobics are great on your joints and you can do much more in the water than you can do on dry land. At my heaviest I had trouble walkin the grocery store.

Pre band I lost about 100 pounds by watching my food intake and swimming daily. And I do mean daily.

well just an update on my situation!

went to my doctors appointment today, and he want to get me with a dietician...he says my insurance wont cover the lap band?

which isnt true, because i called my insurance before seeing my doc and asked them about the Lap Band...and they said they will cover whatever is deemed medically necessary!! so it looks as though my doc is the type that is against the surgery?

when i told him what the insurance said, he just said again they wont cover it.

my BMI is worse than i thought too--- 61.7

question:

Do doctors get penalized or something by recommending the lap band? or is my doc just a health nut, against the surgery???

thanks!

Many primary doctors are not well versed in the lapband system and will not support it or will dwell on the negative, while others just discriminate against the patient and feel that the patient doesn't have the will power to lose the weight. As all of us know that we can lose weight, however, to keep it off permanently is another story. All my life I dieted and lost weight and my most success was being on Weight Watchers program for a couple of years and I managed to lose over 120 lbs. When I went off the weight watchers program and ended up working a third shift at my job, I gained it all back and then some.

Unfortunately, many, but not all, insurance companies put a high importance on whether your primary supports the lapband via the letter of medically necessity and approval. I was really lucky that my primary has 10 lapband patients and is all for it and was extremely supportive.

My advice to you? If this is what you really want, I would look for a primary that will support you. In the meantime, I would attend a seminar which gets the ball rolling. The bariatric program will contact your insurance company to find out what their requirements are. Your letter of necessity comes later and the lapband doctor may recommend a doctor on your plan. Your BMI and HB pressure may be all you need without your primary on board. Keep us posted. Jake

I would switch doctors. I called several doctors to see who would approve lap band if necessary. find 1 that is more understanding. if you know of anyone who has had the lap band ask who they went with.

I'm in the same boat! :/ My doctor is a super thin Asian lady that obviously has never had a weight issue ever in her life. She thinks it's just so easy to just eat right and exercise everyday. After 30 years of making all the wrong food choices and building bad habbits, it's extremely difficult. I want to get the lap band, but I'm going to have to get a different doctor!

I called the practice I was going to get surgery through and asked for their advice on a primary doctor. I did not need a letter from my doctor, but wanted someone on board with the procedure.

well just an update on my situation!

went to my doctors appointment today, and he want to get me with a dietician...he says my insurance wont cover the lap band?

which isnt true, because i called my insurance before seeing my doc and asked them about the Lap Band...and they said they will cover whatever is deemed medically necessary!! so it looks as though my doc is the type that is against the surgery?

when i told him what the insurance said, he just said again they wont cover it.

my BMI is worse than i thought too--- 61.7

question:

Do doctors get penalized or something by recommending the lap band? or is my doc just a health nut, against the surgery???

thanks!

My suggestion is... if you haven't already, attend a seminar of the Lap band doctor your choice. After the seminar they usually have the insurance coordinator there and a few other staff members to answer question. Explain to them you would like the name of a PCP who they deal with on a regular basis concerning Lap Band. They should be able to hook you up with at least a few PCP docs who you can see. If the Lap Band surgeon's office deals with these PCP docs, they should have no problem recommending you for Lap Band.