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

[FXDF2008 14]

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.

[IowaAndy 95]

I had the lapband 2 years ago and lost a total of about 90 pounds and then it stopped working as I think that I had way too much weight to lose for the band to be totally effective. My insurance would not pay to have the band removed and if I would have had my doctor do it here in the US it would have had to have been done in 2 surgeries. The first surgery to remove the lapband and then to wait 2-3 months before having the sleeve. The total cost of the 2 surgeries for me would have been out of pocket and it would have been over $40,000 total. I could never had been able to afford that. I checked into surgery in Mexico and decided on Dr F Garcia. I had my band removed and the sleeve done in 1 procedure for around $6,000. I did have some erosion after 2 years but it was not bad. I am not sure how much erosion you have so can not speak to whether or not you could have this all done in 1 procedure in Mexico should you decide to go that route. I know how disappointing it can be with insurance here in the US. Are they saying that you want the band removed for cosmetic purposes?????? Do not understand that. I would go and speak to your surgeon and see if he can come up with an acceptable diagnosis for them to have the band removed. If you are having some type of issue I do not know how they can deny you the removal of the band. Now the second questions is whether they will pay for a sleeve once you have the band removed. I know my insurance was not paying for any sleeve procedures as they were still classifying then as experimental. They would have paid for a bypass but that is not what I wanted as I do not really think they are that good for your overall health and have lots of side effects.

[MissMinnie 5]

HI,

I self paid for my band and when it needed to be removed my insurance would not pay. After LOTS of investigation I went to Dr Aceves in Mexicali and it has been a great 11 months since my band is gone. I do have insurance it has a WLS exclusion and of course when I got the band I never thought it would need to be removed or all of the horrible problems with it.

Good Luck and be careful. You might want to get the Fluid out of your band until you get it removed, you wouldn't want it to get worse.

[MissMinnie 5]

HI,

I self paid for my band and when it needed to be removed my insurance would not pay. After LOTS of investigation I went to Dr Aceves in Mexicali and it has been a great 11 months since my band is gone. I do have insurance it has a WLS exclusion and of course when I got the band I never thought it would need to be removed or all of the horrible problems with it.

Good Luck and be careful. You might want to get the Fluid out of your band until you get it removed, you wouldn't want it to get worse.

Forgot to say Dr Aceves did my band to sleeve revision in ONE surgery......

[FXDF2008 14]

I had the lapband 2 years ago and lost a total of about 90 pounds and then it stopped working as I think that I had way too much weight to lose for the band to be totally effective. My insurance would not pay to have the band removed and if I would have had my doctor do it here in the US it would have had to have been done in 2 surgeries. The first surgery to remove the lapband and then to wait 2-3 months before having the sleeve. The total cost of the 2 surgeries for me would have been out of pocket and it would have been over $40,000 total. I could never had been able to afford that. I checked into surgery in Mexico and decided on Dr F Garcia. I had my band removed and the sleeve done in 1 procedure for around $6,000. I did have some erosion after 2 years but it was not bad. I am not sure how much erosion you have so can not speak to whether or not you could have this all done in 1 procedure in Mexico should you decide to go that route. I know how disappointing it can be with insurance here in the US. Are they saying that you want the band removed for cosmetic purposes?????? Do not understand that. I would go and speak to your surgeon and see if he can come up with an acceptable diagnosis for them to have the band removed. If you are having some type of issue I do not know how they can deny you the removal of the band. Now the second questions is whether they will pay for a sleeve once you have the band removed. I know my insurance was not paying for any sleeve procedures as they were still classifying then as experimental. They would have paid for a bypass but that is not what I wanted as I do not really think they are that good for your overall health and have lots of side effects.

They say that if I did not meet the criteria for medical necessity when I received my lapband that they would consider it to be cosmetic and would not cover any complications from that surgery even if those complications are life threatening. The thing is, if I had insurance, I would have qualified. I had a BMI of 40 and had sleep apnea. I had repeatedly tried to lose weight, twice with weight watchers and one of those times I lost over 100 lbs only to gain it back over again. That is why I opted for weight loss surgery. I felt blessed at the time to be able to afford to pay out of pocket. Now I'm being penalized for that decision. I'm walking around with a fully eroded lap band (the endoscopy shows it right in the middle of my stomach) which, if it becomes infected, could cause significant health issues and they are giving me the run around. Wanna hear the ironic part? I work for a medical supply distributor. Go figure.

[FXDF2008 14]

HI,

I self paid for my band and when it needed to be removed my insurance would not pay. After LOTS of investigation I went to Dr Aceves in Mexicali and it has been a great 11 months since my band is gone. I do have insurance it has a WLS exclusion and of course when I got the band I never thought it would need to be removed or all of the horrible problems with it.

Good Luck and be careful. You might want to get the Fluid out of your band until you get it removed, you wouldn't want it to get worse.

The first thing my doctor did when we discovered the erosion was to remove all Fluid from my band. Needless to say I've been packing on the pounds since then even though I have some restriction due to the fact that I have an obstruction in my stomach.

May I ask why your band needed to be removed?

[IowaAndy 95]

I can not believe that if your erosion is that bad that your insurance can deny you the surgery and if this could become a health issue and require immediate surgery I do not know how they can deny it. I would call the state insurance office and speak to them about this. What if you would have had the surgery under a different insurance company and then changed jobs and had the problems. They can not have a pre-existing clause for this type of problem. Who is your insurance carrier by the way.

[IowaAndy 95]

And if you erosion is that bad I am not sure if you could have all of this done in one surgery even in Mexico. I think if I were you I would have this done in 2 procedures unless you do some major research about this type of problem and having the surgery done in one procedure.

[FXDF2008 14]

Now that I have figured out how to upload pictures, I will let you decide how bad my erosion is. Now you know why I am on pins and needles trying to get approval. I want this thing out of me before it does even more harm. I know there will be damage, scar tissue and adhesions. That is why my surgeon wants to do it in two phases. You are quite correct that I may not be a candidate to go to Mexico. Time will tell

If that doesn't work just go to the members gallery and look for My Erosion - FXDF2008

[FXDF2008 14]

Oh and my insurance carrier is BCBS of Alabama but it is self-administered by the company I work for.

You ask a good question about if I had been covered by insurance. I believe if it had been approved by another insurance company that there would be no problem. It looks like I will have to convince them that I qualified five years after the fact.

I'm willing to fight for this, but they're making me crazy already!

[FXDF2008 14]

Sorry I had to change the image to take out personal info. New link is below.

[christin 54]

So sorry this is happening to you. When I was deciding between the band and the sleeve, this is exactly the situation that I feared as a self pay patient. I have BCBS, but my company has a WLS exclusion.

I am amazed at how many people have complications down the road with the band. It makes me so grateful I learned about the sleeve during my research process.

I truly hope you can get a removal covered. It is disgusting when insurance companies play these games with people. Keep on fighting!

[FXDF2008 14]

Thanks Christin,

I know they're just doing their job, but this is my health we are talking about. Why the he!! am I paying for the most expensive coverage my company offers and having to fight for them to cover something that is wrong with me. I just don't get it.

Trust me, I will keep fighting for as long as it takes.

[kimmr 5]

FXD,

I self paid for my band nearly two years ago, as the insurance that I had at that time had a WLS exclusion.

I was diagnosed with a slip this past October, and based on my symptoms, I'm thinking it was slipped for most of 2011.

Anyway, I have a different insurance now (new employer) that does cover WLS. My doc worked with me to write a strong letter to my current ins company to cover revision to a sleeve, and they just approved me this week.

At this point, I honestly cannot understand why they approved me so quickly (my paperwork had been submitted less than a week prior). When I got the band, I doubt I would have qualified for any insurance coverage - my BMI was around 39, and I had no co-morbids.

Clearly, I'm not complaining, but I have to admit that I don't understand why they approved so quickly. I've been fighting for months with this same company to cover a $50 prescription, so when we submitted my case, I didn't have much hope. And even though they are covering me, I have a lifetime max of $10K, so I'll still pay quite a bit out of pocket. $10K is better than nothing, though.

That's my story. I know it doesn't help you, but I was in your situation with the self pay, malfunctioning band.

[Wheetsin 714]

FXD, someone above said your insurance company cannot have a pre-existing condition "argument" for your band removal. Unfortunately they can. (I worked for a major insurance company for many years). There is an exception to the pre-existing rule but it's pretty specific around previous group health covering. I don't know if they've been changed for 2012, but for 2011 it was:

Pre-existing = anything that a person sought medical advice or treatment for in a set period before the new health insurance policy took effect. The insurance company will go back at least 12 months, usually more, to determine this.

If you were previously covered by an employer health plan for a minimum of 12 months and you have not had a lapse in coverage of more than 63 days, you don’t have to serve a waiting period under a new employer health plan. Any claims relating to the weight loss surgery would be covered under the provisions of the plan.