My insurance covers LAPBAND, but I need to be approved for it, My doctor sent a letter to the insurance, but I'm not if what he did was right, what do you normally send into the insurance?

This is a copy of part of an email response from my doctors office regarding what I would need to do prior to the initial appt to speed up ins approval.

Hi Ms Beaher

Yes there are a few things that you can do before your appt. These can be done in any order

you will need to meet with a nutritionist which can be done at Houston Northwest Medical center # 281-###-2600 call this number and go ahead and schedule an appt this month and next month(December) your insurance may require a three month physician supervised diet and exercise program, So you will need a total of 3 consecutive months (keep your appts around the same time each month). Also your insurance company requires written documentation that you are mentally ready. So you will need to meet with a psychologist I can provide you with some physician that are familiar with the lapband procedure. Also make sure you bring all your medical records a five year history with your weight on the documents and any information to determine your health. If you can obtain a letter of recommendation from your primary care physician that would be great. Well I look foward meeting you the beginning of the year. Happy Holidays

You may not need all of this....it is all dependent on your ins. plan and what the ins company tells you doctors office that you need for approval. Have you read your plan? DOes it indicate what is required for approval? hope this helps

Hi everyone, I am new here and am proceeding with the process for approval from my health insurance. I am at BMI 34 and typically the minimum is 35. I have been told that Anthem (ins) has approved BMI at 34...........I don't think the doctor would encourage pursuing if he didn't feel it would be approved. (?) Anyone have any related experieonce? thank youG

Famous,

It really depends on what your insurance requires. I have Empire BCBS and they require :

Medically Necessary:

Gastric bypass and gastric restrictive procedures with a Roux-en-Y procedure up to 150 cm, laparoscopic adjustable gastric banding (the Lap-Band® System), vertical banded gastroplasty, or biliopancreatic bypass with duodenal switch as a single surgery, is considered medically necessary for the treatment of clinically severe obesity for selected adults (18 years and older) who meet ALL the following criteria:

1. BMI of 40 or greater, or BMI of 35 or greater with co-morbid conditions including, but not limited to, life threatening cardio-pulmonary problems (severe sleep apnea, Pickwickian syndrome and obesity related cardiomyopathy), severe diabetes mellitus, cardiovascular disease or hypertension; AND
   
2. The patient must have actively participated in non-surgical methods of weight reduction; these efforts must be fully appraised by the physician requesting authorization for surgery; AND
   
3. The physician requesting authorization for the surgery must confirm the following:
   • The patient's psychiatric profile is such that the patient is able to understand, tolerate and comply with all phases of care and is committed to long-term follow-up requirements; and
     
   • The patient's post-operative expectations have been addressed; and
     
   • The patient has undergone a preoperative medical consultation and is felt to be an acceptable surgical candidate; and
     
   • The patient has undergone a preoperative mental health assessment and is felt to be an acceptable candidate; and
     
   • The patient has received a thorough explanation of the risks, benefits, and uncertainties of the procedure; and
     
   • The patient's treatment plan includes pre- and post-operative dietary evaluations and nutritional counseling; and
     
   • The patient's treatment plan includes counseling regarding exercise, psychological issues and the availability of supportive resources when needed.

In English, a letter from primary stating diets tried and failed with post op programs in place, letter from nutrisionist, psych eval. They don't require the 6 mo diet that some do. I completed everything today and now just waiting for all the reports to be finalized and sent to the insurance company.

Call your insurance carrier for detailed information.

Good luck!

famous: have you seen a surgeon yet or is that after your upcoming seminar? THey can usually give you a list of what they want and they can call your insurance and ask what they (ins) want. I just asked my PCP for the referral to the surgeon (even though technically my ins doesn't require referrals) and put in a request for my medical records. I asked that they release the MR to me so that I can give them to the surgeons. I don't have my PCP MR but I have all my other MR because I always keep them on file at home. Labs, tests, hospital records etc. If your surgeon has a website they sometimes list what they like you to have on the first consultation or their PR person might be willing to tell you. Depends on what kind of mood they are in and how busy they are.