When I talked to my insurance company, they informed me that LB would be covered. They even sent me a new book outlining my benefits. In the book it states under Noncovered Services:

Tretment and monitoring for obesity or for weight reduction,

regardless of diagnosis, excluding surgical operations.

I wanted to make sure that I understood that statement, so I called again. The person I was talking to said that they would not cover anything other than surgery. I asked again just to make sure that I understood her correctly "So Lap-band surgery is covered?" She said, "Yes".

Well, today I got a letter in the mail that states:

Benefits are not available for those services which have been

determined to be not medically necessary per physician review.

Therefore, no benefits are available for laparoscopic bypass surgery

(LAP band), as this has been determined to be not medically

necessary, as it does not meet medical policy criteria, as there is no

documentation of two years of medical management.:girl_hug:

So now I have to start the appeal process. I just find this very depressing. Does this mean that I have to pay out-of-pocket for "two years of medical management" because they will not cover that?

I just went and and got on the scale, I'm 224 lbs, I am 5'1", that puts my BMI at 42.32, I have sleep apena and joint pain. I realize that I don't have a lot of medical problems YET, but I was hoping to get it under control before I did. But even with the few problems that I have, my doctor, not a bunch of people who have never even spoken to me, beleives that the surgery IS medically necessary. Dam it, I just don't want to wait two more years. I'm even quiting smoking this Saturday, June 10. Not only will my surgon not do the LB is you smoke, I decided that if I plan on getting healthier, I need to do everything to get healthier.

I will have to call my doctor tomorrow and see what they have to say.

Thanks for letting me vent, I know some, if not most of you will understand.:think

I think an attorney may help? I wonder why people don't get them involved more often?

I have Personal Choice Blue Cross PPO and was approved in 5 days. My doctors office did all the paper work.

I contacted a lawyer early on and there are a few that are more than willing to help, I just can't afford the price! :phanvan I would go ahead and self pay if I could afford it, but that's not an option at the moment, either, so I guess I will just have to be patient.

have them write a letter on your behalf. it will work.....

Appeal. Look up appeal letters on this site and obesityhelp.com.

Have every doctor you have seen recommend it. I had one from my PCP, OBGYN, and chiropractor. Do you go to a gym? Have them print out your log ins. Oh and regarding the doctors office visits. I was asked to have 12 months (but got away with 6). I went to my doctor for blood pressure checks, and he just happened to write down my weight and tell me to exercise, went to my doctor for a cold, and he wrote down my weight and told me to exercise, etc. Weight was never the primary diagnosis, but it was on there. It is all in the way you "play the game".

I put a sample of my letter on the following thread:

http://www.lapbandtalk.com/showthread.php?t=15700

It has CPT codes and other stuff insurance likes to see, based on the research I did.

If you want it bad enough you will work for it. I worked from October '05, and was just banded this past Monday. Insurance does not want to cover it, but if it is medically necessary they will, or the insurance board will make them.

Good luck!

Hi--I have BCBS of Alabama & I was approved for "Laparascopy, surgical gastric restrictive procedure; placement of adjustable gastric band and subcutaneous port components." Which is what my approval letter said. I previously tried in Sept 05 and was denied advising that I needed a 6 mo supervised weight loss plan. I had no co-morbidities except for the fact that I started having ankle swelling after I began to exercise with a trainer. I did the 6 mo diet and my Dr's ofc resubmitted me and I was approved. However they did indicate that benefits for complications or subsequent surgery will not be covered. They will also not cover any related office visits or fills. Its not the best thing but not the worst, they did pay for my surgery. Good luck to you keep trying and appeal!!

I have BCBS too. I didn't even bother because once I made the decision, there was no way I was going to wait another year for further documentation of my failures. My total cost for surgery was 8,000. All my pre-op and office visits were paid via the insurance company, I think because they had no idea what the testing was actually for. That saved me about 5,000 dollars. (I had to have 2 sleep studies before they would schedule a surgery). Anyways, it can be financed. You can look up capitol one heath care loan and apply online if you do not have the cash up front. I looked into it a little and if I remember correctly you can pay off the loan in like 5-6 years so it comes out to very nominal payments a month. I just paid up front so I don't know all the details, but there are options.

To pplqueen,what city and state are you in ? and could you please help me? I'm so desperate. I have had BC/BS insurance for well over 12 yrs. and I can't afford an out-of-pocket expense even though my life depends on it. Also I'm very happy for you good luck with your surgery.

My total out of pocket was $512, but I had another insurance and it picked that up.

Yep - BC BS sucks. No doubt about it. I had to fight for four months before I got approval.

Sounds like they want diet medical management - It may be as simple as documenting your diet history and the fact that you have been obese for a while and tried to combat the problem through "traditional" means.

If you want, I will forward my appeal letters to you. Just PM your e-mail address.

Good luck and try to be patient.

Hugs!

I just got back from vacation and low and behold, my second denial letter. This one also states that it is not medically necessary. But they did give me something to work with. This one states:

Our Medical Policy states:

The screening criteria listed below should be utilized before any surgery would be considered medically necessary:

1. The patient must have morbid obesity or a BMI of 35-40 plus significant co morbidity.

My BMI is 43+; I also have sleep apnea, diabetes and joint pain. I also have other medical condition that would be improved with weight loss.

2. The duration of obesity must have exceeded five years.

I have been fat for a long time and have the weigh in to prove it.

3. No identified treatable medical causes.

Nope, just fat.

4. Age >/= 16 years of age.

I’m 39.

5. Evidence in medical records of nonsurgical obesity treatment over a minimum of two consecutive years of at least four face to face discussions with MD/DO physician or physician substitute with a documented treatment plan (diagnosis plus diet at every visit and exercise recommendation at least once).

This might be tricky. I have my records from LA Weight Loss from 2005. Really they are in my medical records because LA would not send them to me. And I know that I have talked to my doctor about exercise at least once in the last year.

I met someone at a support group meeting who has the exact insurance as I do (we both work for the state) and she was approved without any medical problems. I am trying to get intouch with her. I also have a call into our "person" who sets up our insurance contracts and hope to shed some light on why I keep getting denied.

My doctor is out of town until next week, so I will have to wait until then to talk to him and get his help. If they will take the LA Weight Loss, then I only have to wait until December to get approval. Please pray that they will accept it, I can’t go self pay.

YIKES!!! I'm glad all the BCBS are not the same. I have BcBs of Mass. and it's really a good plan. They cover lap. bypass and lapband. the requirements are bmi 40 and over or bmi of 35 and over with 2 co morbid diseases (which they list on the website). I had to show I had a weight issue for five years or more. There is no six months of supervised diets. For, me it was a pretty quick process, even though I was complaining that it took forever. My total start date to surgery date is around 3 months. The insurance company has 30 days to approve or deny my request of surgery. I was giving a date before hand, so the ins. comp. said it would take 15 days. I'm not saying this is a piece of cake. I know the insurance company is a hard ball player in reguards to the co-morbid diseases and it's only going to get worse. I hear they are changing the rules come April of next year.

Just for those who may ask.. My BMI is 38.8. I've had several back surgeries, I have a intrathecal pump implanted for pain, very high BP, joint pain in the back and knees. I have not been giving a letter of approval just yet.. BUT my Dr. has been told I was approved through the case manager. When I called BCBS, I'm told .. still pending. BUT the customer rep. stated that the case managers work with the hospitals cooridinaters and most likely know a heck of lot more info. than she has on her screen. The rep then went ahead and told me that my pre op testing and surgeon meeting would not have been approved for next week, if I wasn't approved for the surgery. Sorry for the long post, just wanted to make sure I didn't leave anything out.

Anyhow, I'm sorry to hear that so many people are having issues with insurance. It's amazing that they will pay for meds, testing and everything else that relates to being overweight.. but they won't give us a chance to use a tool to help prevent or even stop these problems. WLS isn't new.. you would think this would be pretty much standard by now. I do think that there are some people sandbagging the system.. but there are far more who truly need this and to be denied.. doesn't make sense.

One last thing, I was able to submit WW payment slip, Diet workshop, South beach diet online payment info., gym receipts and many more. I'd shove it all in their face. Also.. a huge plus is to write a letter stating why you are a good candidate for surgery. I went as far back as my teen years. I called my Mom and she gave me info. that I didnt' know about. I also got my pediatrician notes. My Mom has a copy of my file.. neurotic or not.. LOL

:update: AS OF TODAY, JULY 6TH, AT 3PM. I HAVE BEEN 100% APPROVED.

Hi everyone! I'm in need of a few good friends right now. I've been researching lap-band for 1 1/2 years. Had BC/BS of Ne. They refused to cover for ANY reason. Iowa medicaid only covers bypass after three years of documented physician assisted dieting. Now I have United Health care-the top "premier"-THEY said it was EXCLUDED, but would take it on a Case-by-case basis with a surgeon's predetermination letter. Needless to say I'm so depressed because I was denied-the co. said"You have a policy exclusion for obesity surgery" DUH!!!!! I feel hoodwinked too since we could have changed our coverage by June 28 and not paid out $300/mo. for insurance we can't use!!! any good advice?

Does anyone have United Health care-Overture Premier?(Tier 3)

Bumped for kellbelle

Sorry all:I didn't know what i was doing...didn't intend to "bump" Mrs. Husker's thread. kellbelle