Just starting to explore options...help!!!

July 17, 2004

Hi All,

This is my first post, and I'm interested if my insurance would ever cover the lap-band procedure. I'm in S. California and have Blue Cross Blue Shield HMO through my work (I know yuk).

I'm a 5'7 , 41 yr old female and weigh 280lbs. I currently take 2 types of high-blood pressure medicine (for the last 4yrs and RX for extreme heartburn). I know my BMI is over 40. I'm also noticing more muscle aching and issues with energy, etc. (the usual over-weight issues).. I have to take control of this issue as it's just ruining my day to day life and I want to be around to watch my 10yr old grow up.

I have a long record of weight loss procedures I've followed be it Weight Watchers, Zenical, Atkins, Suzanne Sommers, etc. All have been somewhat successful, losing up to 30-40lbs, but always end up gaining back plus extra.

As I'm now 41, I just want off this merry-go-round once and for all, and after reading about the differenct options, I feel Lap-Band seems the least invasive and reasonable option for me.

What I really need is guidance on what I need to do first. All help is greatly appreciated!!!!

If I must end up paying for this procedure out of my own pocket, I am prepared to do so, but would like to try for insurance coverage if at all possible. Also, would I have better luck if I switch my coverage to PPO?

Again, thanks for all comments.

sassaay · July 17, 2004

Hi Brando,

Not sure my response will be much help, but my advise would be to do as much research as possible and talk to your primary care physician.

I know that there are a lot of other folks on this board with expertise in the area of Insurance coverage for the band, so I am sure that they will respond to you real soon.

It sound like you are an ideal band candidate, so one piece of advise would be to document all of your past weight loss attempts. You want to have as much documentation as possible to send to your insurance company if necessary.

Good luck and keep us posted on your progress.

New Hope · July 17, 2004

You certainly don't have anything to lose pursuing the insurance co. first. They're all different. The insurance co. may cover WLS, but your company may have a specific exclusion regarding WLS. Just be prepared to jump through many hoops. Mine first denied, then approved on appeal, but took 8 months. Some have been approved in as little as 2 days. Best of luck to you!

Alexandra · July 18, 2004

Hi B,

Advice from others is usually not worth much with regard to insurance issues, because the only thing that really matters is what your policy says. If your policy is like many standard plans, treatment for morbid obesity is covered if you qualify medically. It sure sounds to me like you do, but only your carrier will be able to tell you what their specific criteria are.

The place to start, in any event, is with your primary care physician. If you haven't had a physical recently, get one, and have him note in your records a diagnosis of Morbid Obesity (the code for which is 278.01). Assuming that condition is covered by your carrier, all your testing and so forth should be covered as well. But the first thing to find out is what your carrier's position is on treatment of morbid obesity.

Dig out your coverage documents and find out what they say. If they're not clear, call the carrier or your h.r. department (if your company is self-insured) for clarification. You're entitled to know.

Good luck, and let us know how it unfolds!

July 18, 2004

Thanks to all for the information. I will speak with my HR dept. tomorrow.

GeezerSue · July 18, 2004

According to the Blue Cross CA website, they consider the band experimental. Which is bunk. And they use antique literature to back up that claim. (Additionally, some policies may not allow for ANY weight loss surgery.) You should contact Don Mills at Inamed and ask him if he has had any successful reversals of that policy.

http://medpolicy.bluecrossca.com/policies/surgery/morbid_obesity.html

Vera · July 18, 2004

Hi Brando,

Just want to add, I have California Blue Cross PPO and my policy does Not cover Banding. Good Luck.

July 19, 2004

Vera,

Did you end up doing a self-pay?

Thanks,

B

Vera · July 19, 2004

Yes. $10,850 Dr. Sanchez in Monterrey Mexico. I used Credit, and almost have it paid off.

As soon as I came home I put in a claim to Blue Cross. Three weeks later they requested the doctors instructions/proceedures. I sent that in and three days later was denied. I just sent in another claim and waiting on a responce. I'm just going to keep pushing claims. :guess

July 19, 2004

OK, I called, they will cover a gastric bypass, but not the band. Can I fight for the band as my option? If so, what do I need to do?

Alexandra · July 19, 2004

I faced the same problem with my carrier, Aetna, back in 2002. I eventually won on my third appeal, which was an external appeal provided through New Jersey's dept of insurance. I don't know if California offers a similar third-party review of carrier decisions, so you might want to find that out.

If you are willing to fight the carrier on the "experimental" label, it most definitely can be done. The chance of success largely depends on who will ultimately make the determination. Insurance carriers have internal medical review departments, but if everyone in that department is on the carrier's payroll you can bet they'll toe the party line. Aetna didn't hesitate a second to deny my first and second appeals of their initial denial, because it was their company policy to exclude banding no matter what. This was upsetting but not surprising.

But then the decision got taken out of their hands, and I quickly got a notice that their denial was overturned. The external review board didn't agree with Aetna's policy that the band was investigational/experimental, and now that some time has passed Aetna has even embraced the band a bit more than they used to. I think all carriers will come around, eventually.

If you don't want to wait you should just proceed with your request for precertification and then follow the carrier's instructions about appealing. If there is a possibility for external review at any point I'd say you have a decent chance of winning. If California does not provide for any external review of insurance carrier's decisions, then you'll likely be out of luck until BCBS of CA comes to the obvious conclusion that the band is neither investigational or experimental. How much time that could take is anyone's guess.

GeezerSue · July 20, 2004

First step...call Don Mills at Inamed and ask if he has had any success with fighting the BC "experimental" thing. Sometimes, they have had the surgeons explain whay the patient is NOT a good candidate for the bypass and they get through that way.

Anybody got Don's number close by?

Other first step...find out if your employer is a self-pay for insurance. If so, they are actually the ones making the decisions and BC is just administering the plan. If not, they are covered by the CA state insurance commissioner (they have a web site.) They have a three times and then to outside review thing.

One thing I found handy when I was on the phone pretending I was my daughter (her job at the time did not allow for personal business calls) fighting for her breast reduction with Aetna...dumb-sounding-questions-with-a-plan seem to get their attention. As in, "Okay, so does this count as the first time you've turned me down? So then, does this go to outside appeal after the second time and the third time is the outside appeal or do you have to actually turn me down three times before we go there...I'm sorry, but this is new to me and I want to make sure I understand it all." And ask everyone how to spell their name, and explain that's it's nothing personal but you know it's probably going to end up going for outside review and you at least want to spell the names correctly. Be loving and kind and their new best friend.

Also, I did end up using Aetna's journal citations for our kid's appeal. If I could find a contrary opinion in the abstract, I quoted it, just like they did. if I could find a later publication by the same researcher which contradicted the first citation, I quoted it.

They never DID turn her down the second time, because they knew that she was ready to go the whole way and that they would lose.

Go for it.

Sue

leatha_g · July 20, 2004

Originally posted by GeezerSue
Anybody got Don's number close by?

Got his email, will that help? don.mills@inamed.com

GeezerSue · July 20, 2004

Just so you can see what we wrote. I don't think this was our FINAL appeal letter--there may be a later version--but it was the ONLY one.

~~~~~~~~~~

Name

Address

Los Angeles, CA 90036

Phone

14 April 2003

Chris Jagmin, M.D., Medical Director

Patient Management Department

Aetna Insurance Company

2777 Stemmons Freeway

Suite 300

Dallas, TX 75207

Re: Your denial letter dated: xxxx

Member Name: xxxx

Date of Birth: xxxx

Reference #: xxxx

Employer Name: xxxx

Employer Account Number: xxxx

Dear Dr. Jagmin,

I am in receipt of your denial letter dated xxxxxxxxx and submit the following information in support of this appeal for reconsideration:

It is my understanding that I do meet Aetna’s criteria for coverage of breast reduction surgery because my surgery will be performed for reconstructive indications, I am over age 18, and I have met the following criteria, as documented by my physician and chiropractor:

A. I have a diagnosis of Macromastia, and

1. I have persistent symptoms in the following five (5) anatomical body

areas below, affecting daily activities for at least five years:

* Pain in upper back

* Pain in neck

`* Pain in shoulders

* Headaches

* Pain / discomfort / ulceration from bra straps cutting into shoulders;

AND

2. ALL of the following criteria have been met:

a. Photographic documentation confirms severe breast hypertrophy; and

b. My PCP has documented that chronic pain symptoms are caused by

macromastia; and

c. I have undergone an evaluation by my PCP who has determined that ALL

of the following criteria are met:

i. The pain cannot be solely explained by a musculoskeletal

condition (e.g., arthritis, spondylitis, acromioclavicular strain); and

ii. Reduction mammoplasty is likely to result in improvement of the

chronic pain; and

iii. Pain symptoms persist as documented by the PCP despite years of

therapeutic measures such as:

* Supportive devices (e.g., proper bra support, wide bra straps)

* Analgesic / NSAIDs interventions

* Physical therapy / exercises / posturing maneuvers

Remaining, then, is the issue of the quantity, in grams, of breast tissue, not fatty tissue, which will be removed from each breast, based on my body surface area (BSA). Your chart indicates that the amount of tissue you require be removed is 1055.7 grams per breast, while the peer reviewed literature you cited (1. Miller, et al.) argues that the quantity of tissue removed did not correlate with outcome in the mammaplasties studied.

Five board-certified plastic surgeons have now examined me and agree that a substantial amount of tissue needs to be removed from each breast for non-cosmetic reasons. The weight of the tissue those five surgeons have proposed removing ranges from a low of 450 grams to a high of 1050 grams, even though each surgeon proposed leaving the same amount of breast tissue. The surgeon who proposed the 450 gram reduction is the one whose preauthorization you have rejected. Since that request was submitted, I have elected to utilize the services of a different physician, a board-certified plastic surgeon within Aetna’s network of providers, who--like the other four surgeons and the current literature (2. Bruhlmann Y, et al.)--recommended a reconstructive removal of less than the 1055.7 grams on your chart.

While the use of BSA as a general guide seems reasonable, complete reliance on that criteria would suggest that Aetna does not consider bone structure, muscle mass or other specifics regarding the individual. All of those factors--and others--were taken into consideration by the five board certified plastic surgeons who examined me, prior to their stating that such surgery is indeed medically necessary in my specific case.

Attached please find statements from my PCP and Chiropractor. I look forward to a positive response to this appeal. Meanwhile, xxxxxxxx, M. D. will be submitting a request for coverage verification and authorization for this surgery.

Sincerely,

xxxxxxxxxxxx

Enclosures: 2

xxxxxxx, M.D.

xxxxxxx, D.C.

References:

1. Miller AP, Zacher JB, Berggren RB, et al. Breast reduction for symptomatic macromastia. Can objective predictors for operative success be identified? Plastic Reconstruct Surg. 1995;95(1):77-83

2. Bruhlmann Y, Tschopp H. Breast reduction improves symptoms of macromastia and has a long-lasting effect. Ann Plast Surg 1998 Sep;

41(3):240-5

~~~~~~~~~~

Pretty good if I say so myself!