Hate Jumping Through Hoops

Jameskc · June 23, 2008

I haven't minded most of the preliminary testing and evaluations. I understand the nutrition eval. I understand the psych eval. But the 6 month doctor approved diet is silly, in my view. Look, we all are considering lap band partly because we have dieted for years, only to put the weight back on. Whats more, if I am even remotely successful at dieting, I could disqualify myself for insurance coverage. My bmi qualifies now, but what if I improve it during the diet? Will I be denied?

cheryl1952 · June 23, 2008

Do you have Humana? I have read that you don't have to lose a significant amount of weight they just are interested in the physician documentation that you have gone there and recorded your weight and been discussing weight loss and exercise. Who knows I think they are just assuming that alot of people will just give up and they won't have to fool with them.

Cheryl

FeliciaLevy75 · June 23, 2008

Hi James,

The insurance companies have a fair justification for the diet: they need to see a patient commit - right now, regardless of history - to doing anything necessary to lose the weight Think of it this way: if losing the weight is so important you would undergo surgery, then the diet is just a small way to get ready for it.

It's hard, James, dieting alone or dieting - changing your lifestyle - as a bandster. Either way it's going to take commitment and dedication like nothing before. That's all they are asking for.

Does it always make sense? Not really. The money spent on WLS by the insurance company is a drop in the bucket compared to what is spent dealing with obesity and related issues. That said, it's a way for them to perform their due diligence; let's face it, they don't want to spend any money at all if they can help it.

That said, there is both good news and bad news. The bad news is that you want the band now and 6 months seems a long time to wait; the good news is that 6 months is only 26 weeks.... if the doc's diet and exercise can help you lose even a pound a week, that's 26 off your 80 (looking at your ticker)! That's amazing!

As much as I love what my band is helping me to do, you may find that in your zealous (in a good way) chase of the band by following the doctor's diet, you may not need it! Jump through the hoops enough and you may be able to tell the insurance company to take a hike. :grouphug:

At the very least, you can prove to them you are ready for this and, with all the doc's documentation and recommendation, you can get that band!

rlp864 · June 23, 2008

I haven't minded most of the preliminary testing and evaluations. I understand the nutrition eval. I understand the psych eval. But the 6 month doctor approved diet is silly, in my view. Look, we all are considering lap band partly because we have dieted for years, only to put the weight back on. Whats more, if I am even remotely successful at dieting, I could disqualify myself for insurance coverage. My bmi qualifies now, but what if I improve it during the diet? Will I be denied?

Yes, you could disqualify yourself. My BMI was 42 before my diet, and 37 after. You want to loose some weight, but not a lot. Maybe 1 pound a week, and then gain some back during the months. This will show that you are able to loose weight, but you are unable to maintain the weight loss without help. I hope this helps, good luck.

oyesican · June 23, 2008

Hello, James, I'm in the same boat. I have Aetna and a BMI 35.6 w/co-morbidities. My advocate said that Aetna does not require weight loss, just nutritional counseling, and it can be for just 3 mos - at least on my plan. So my plan is to build muscle over the next 3 mos but basically maintain and not lose more than 3 lbs, which keeps me at 35. They also told me I have a good shot since I have sleep apnea, and evidently Aetna approves that pretty easily. I only recently went over 35 so I don't have the history either, but I'm going to try for approval anyway. Worst case I may have to be self pay. It's kind of ridiculous but I'll check all their boxes to see if I can get it approved.

KayleighsMommy · June 23, 2008

James,

I agree with you. I feel the 6 onth diet is ludicrous. My theory (shared by lots of others, believe me) is that if they throw up enough roadblocks you will just go away and pay for it yourself.

I have BC/BS of IL, and they are HORRID!!!! I am actually doing self pay this week... though I am a in bit of a different situation. I need to have a hernia repaired (it can't wait 6 months) and I really don't want 2 surgeries.... especially since after I made the commitment to pay they said they wanted a 24 month diet. :tongue: It's not like I have a low BMI (I am 300+ pounds), and have quite a few comorbities.

As for the BMI issue... my understanding (through my ins, at least) that the BMI used for approval purposes is the oone you have pre diet...so even if you drop down you're OK. Possible other companies do it differently.

Best of luck to you.

midwestchickie · June 23, 2008

kayleigh,

Hi, I have bc/bs of IL too...It's nice (ha) to hear they are being difficult. My plan does not even cover it regardless, but my dh wanted me to wait a year and see if it was added to our plan. Sounds like I would have a horrible time getting through the hoops. My bmi is low to start...and 24 mos of diet? Crazy! I'm doing self pay, this post just decided it for me.

James,

I completely understand your point of view..another reason I wanted to self pay...I have a low bmi too and I'd be afraid I'd lose 20 pounds, only to gain it back in a year and go through this whole process again.

oyesican · July 24, 2008

James, have you heard anything new from your doctor yet? Mine said they want to submit in August and are hopeful that my 5 year hidtory of being "overweight" will satisfy the time frame requirement, even though my BMI has not been over 35 for very long. Just wondering if you're still waiting.

ciconetti · July 25, 2008

Hey! I was reading through all these different comments. I too have BC/BS of IL. The lady at my doctors office (Lapband doc) said she has never delt with BC/BS of IL. I have done the siminar, and the dietician, and therapy evaluation (they both say IM READY), and a letter from my PCP stating he reccomends this for me and states I have tried multi diets over the past 5 years (under his care) I have Hypothyroidism and have for 12 years, and its under control with meds. I have 2 co-morbidities,and my BMI is 43. What hoops did you have to go through and how soon did you get approved?

Hope to hear back... Thanks!

GOOD LUCK!!!