I went to a Lap Band surgeon for my first visit. I knew that it would be borderline if insurance would approve me. The surgeon said that I would not qualify for my insurance to pay. My BMI is 38 but I do not have high blood pressure, diabetes, nor do I have sleep apnea. I have degenerate disks in my back but he said this would not get it approved. Although I have battled my weight my whole life, my 5 year weight history doesn't help me because some of my weights were lower at the time of my doctors visits a few years ago. Although they were obese weights they were not severe enough. **I need some advise. I have BCBS. My concern is if I pay for the surgery, what if there is a complication or what if I have to have the band replaced? Will insurance cover any complications? Has anyone been through the same situation? Help?:confused2:

Marie....that sounds odd to me with your back issues that it wouldn't be approved by your insurance. Is the doctor even going to try to see if it gets approved? If not...I recommend trying another bariatric center or surgeon because BCBS is generally very good to deal with. You know you can always call BCBS yourself to see what the qualifications are for the surgery in their eyes. They will be able to tell you that and also they'll be able to tell you if your employer or whoever you get the insurance through has any stipulations towards bariatric surgery. Some companies allow it others do not or do but, with certain requirements. Good luck!

Thank you for the reply. You were my first reply!! I joined today. I am going to call BCBS tomorrow. This is something that I want terribly. I am 37 yrs old and enjoy being active and outside but at this weight I do not enjoy being active and outside. I am ready to do something about it. I had one visit with the doctor. He did not submit my information but said that I would not qualify based on his experience. Self pay scares me. I will ask BCBS questions about self pay also. Thanks for the advise.

I am in the same boat as you. BCBS Peehip. BMI also 38, and I'm 37 years old. Your post is like reading my own story. I have considered gaining a few pounds, but like you, my past weight was lower, and I'm required to complete a 7 month physican assisted wl program. If I lost weight that would put me back below the required 40 bmi. I do not have other health issues. I am also worried about poblems, and payment by insurance if they occur. I have been told by a receptionist at the Dr. office that if the procedure needed removed (life threatening) they would pay.

Kamica, isn't it frustrating? If you gain weight do they still look at your weight history? I am guilty for thinking the same thing. But, you know, I don't think that I can stand to weigh more!! I already hate finding clothes to wear in the morning! I saw someone else say that if the band needed to be removed that the Dr. would pay. I am going to check on this. What is the 7 month program you have to do??

This boat is getting crowded. I have the same situation, although I am older than you two. I am 50 years old, with a BMI of 38 and the only health issue is degenerative disc; L4-L5. I will be footing the bill for this journey as well.

Oh my...same boat with the discs and the same ones. Who is your insurance with?

What do you know about self pay?

I have Aetna insurance. I am a nurse and the insurance is through the hospital. I have a co worker who just got banded 3 weeks ago witht ehsame insurance, she was covered due to high BP, sleep Apnea. It took her a year to jump through the hoops.

What I know about self pay is just that ; You pay for everything. Doctors bills anesthesia, hospital bills.

However, would your insurance pay if you had complications, I guess that woud depend on the insurance and the complication.

I have BCBS, I was approved and had surgery. My BMI was higher than yours, but still I’m wondering your surgeon can tell you that you won’t be approved without first having you to the tests. I had to do a six month supervised diet. I did, and I lost maybe twelve pounds – naw I don’t think it was even that much. I’ve read where quite a few bandsters went on those diets and simply didn’t try very hard to be successful. I tried, but hell if I could do an 1800 calorie a day diet on my own, I would not have needed a band. In addition, I had to get a psychological evaluation, cardiologist clearance, pulmonary clearance, and primary care clearance. Your surgeon simply looked at your BMI and weight history and made a decision? Go back to the doctor that diagnosed your back problems. Are you in pain? If so, tell him you are in pain. My orthopeadic surgeon was always telling me I needed to lose weight. If yours is the same, tell him/her to put it in writing. That goes a long way. I hope this helps you. Good Luck.

Your employer controls the rules of the insurance. For instance, some people using UHC have to do 6 months of dieting/nutritionist etc but my husband's employer paid for some nice coverage, and basically the rule for me is "medically necessary." So, you really need to talk to someone at the insurance company. They also might have provisions for an appeal process.

I am in the same boat as you with the lack of insurance. I went to my first seminar on Wednesday and all of my fears of the surgery are gone. When I looked at my insurance coverage, they exclude the surgery. Any ideas anyone has would be appreciated :glare:

Marie,

Do what I did. Fly from Charlotte to Denver. Enjoy a few days of vacation (Denver area is terrific). Then go see Dr. Kirshenbaum for a band at just under $10,000. Fly back to Charlotte, then lose your weight. You can get fills from Dr. Ahigian in Denver (NC) at Fills Centers USA. Dr. Ahigian is a great fill doctor. I also think there is a new New Hope Bariatrics in Charlotte that does it pretty reasonably for cash. Good luck.

I initially was kind of in the same boat. 39 BMI, had high blood pressure, high choles., thyroid, arthritis, you name it. But my insurance required under a 40 BMI, that you had to have either diabetes or sleep apnea, which I knew I didn't have diabetes but wasn't sure about the apnea. My primary care dr. was fabulous and very supportive, sent me for a sleep study and, lo and behold, had sleep apnea. Now everyone around wasn't surprised. Guess I was the only one not disturbed by snoring...lol. But still had to jump through all the hoops for the six-month program. And even gained weight to make sure I still fell within the weight guidelines because I knew that part of six-month plan was to lose 10 percent and had to be careful not to drop below the required weight.

My daughter was also refused for having no comorbidities. She flew from NYC to Houston to Dr. Spivak who is one of the original 14-member team that introduced lap-band to the US...pretty much as long as you're a 35 BMI, he will do it.

I would think it wouldn't matter as far as complications after the fact as to whether insurance will cover. it's then a medical problem and they should still cover, but there are plenty of attorneys out there that do nothing but litigate insurance company denials. So I wouldn't worry about that. Dr. Spivak in Houston last year was 13,500 but my daughter did all of her follow-up/fills in NYC.

Good luck

Trisha

Not all BCBS are created equal. Mine makes it almost impossible. In addition to the six month medically supervised diet, you have to exhibit a 3 year history of BMI over 40. If at any time during the diet or the three years, your BMI goes below 40, you have to start all over again.