What does this mean???

[MiamiChick1532 0]

Ok so I finally decided to do the LapBand, I called my insurance (GreatWest) and they told me they do cover the surgery but only under these conditions 1. BMI over 35 (Which im there)

2. Weight management history which includes all of the following:

A- Five year history of morbid obesity with an BMI of 35+

B - Review of weight management for at least the preceding 2 years

C- Participation in a weight loss program for 6 months (within the last 2 yrs) with hart notes that include documentation of ALL of the following:

1.A dietary program for weight loss which consist of a low calorie diet.

2. At least monthly clinical encounters with healthcare professional who does not perform weight loss surgery.

3. Increased activity/exercise

4. Behavioral modification program supervised by a qualified professional.

5. Weight loss management history includes pharmacotherapy with physician prescribed weight loss drugs or documentation of why parmacotherapy was not tried.

I HAVE NOT DONE ANY OF THOSE AT LEAST NOT WITH A DOCTOR. I'VE DONE THE Atkins DIET AND TOOK FAT BURNERS AND LOST ABOUT 30 LBS BUT OTHER THAN THAT I DIDNT DO ANYTHING ELSE.

WHAT DOES THIS MEANS NOW?????

[thininside28 0]

What I think your next step should be is to see your doctor that is going to preform your surgery or attend the semanar if you have not done so. Most require the semanar before your initial appt. The lap band docs and their office staff know how to deal with the insurance company. They have most likely delt with patients that have had the requirements your insurance requires. I would have never been able to get everything together to submit to the insurance. Your MD's office should be able to stear you in the correct direction! good luck

[JamieNP 20]

My surgeon says that this is what insurances do to try to get out of doing surgery.

Get records of any and all doctors that you have gone to over the years.Even if it was not wt related, there should be a history of your weight there. Now, make a list of ALL weight loss programs you have attempted, diet pills you have taken, wt loss books you have read, exercise programs you have done. Make a list of your weight history, health history, family health history (esp if there are cardiac issues, lung issues, diabetes...anything wt realated) If you can get a letter from any of your doctors, that would be great (ie. my pulmonologist wrote a letter to give to the surgeon) Then go to your PCM and give him a copy of the list. These are the hoops you have to jump through, unfortunately.

[dm5201 1]

I have just been approved by Aetna for the Realize Band. I read our policy closely and saw that I needed to have 5 years worth of medical records showing how much I weighed and blood pressure, and so on. I went to the doctor all the time and all they want to see is that you have had a constant weight gain, loss, and so on. My weight only fluctuated by a few pounds.

I obtained a copy of my chart back to 5 years. I checked that off my list.

Next, I had to show that I had other issues and that I was being treated for it. I am being treated by the following: high blood pressure, sleep apnea (I use CPAP); if you have not had a sleep study, the surgeon may order that; reflux; and joint issues.

The surgeon I went to has a nutritionist, exercise physiologist, RN, and psyc nurse on his staff. I went once a month for 3 months because my insurance requested it. I only had to see the psych person one time initially.

Make a list or if your surgeon's office has one, get the list and work your way down the list. Surely, your surgeon's office has a staff that can help you successfully make this happen. Donna

[dm5201 1]

Comment in: Surg Obes Relat Dis. 2006 May-Jun;2(3):417-8. Insurance-mandated preoperative dietary counseling does not improve outcome and increases dropout rates in patients considering gastric bypass surgery for morbid obesity.

Jamal MK, DeMaria EJ, Johnson JM, Carmody BJ, Wolfe LG, Kellum JM, Meador JG.

Department of Surgery, Division of Minimally Invasive Surgery, Virginia Commonwealth University Health System, Richmond, Virginia, USA. jamalm@mail.medicine.uiowa.edu

BACKGROUND: Preoperative dietary counseling (PDC) before bariatric surgery is mandated by a growing number of insurance payers. Their claim is that PDC improves outcomes and postoperative compliance. We compared outcomes of GBP patients undergoing a mandatory 13 weeks of PDC (n = 72) to a contemporaneous group of patients with no such requirement (no-PDC; n = 252) who underwent operation between January 2000 and December 2002. METHODS: The PDC and no-PDC groups were characterized by similar male:female ratios (1:4 vs 1:4.6), mean age (42 years), mean body weight (324 lb vs 309 lb), and mean body mass index (BMI) (52 kg/m2 vs 50 kg/m2). The PDC group had a higher incidence of obstructive sleep apnea compared with the no-PDC group (41% vs 28%; P < .04) but otherwise the two groups had similar incidences of obesity-related comorbidities. The presurgery dropout rate was 50% higher in the PDC group than in the no-PDC group (28% vs 19%; P < .05). RESULTS: At 1 year follow-up, the no-PDC patients had a statistically greater percentage excess weight loss (67% vs 60%; P < .0001), lower BMI (32 vs 35; P < .015), and lower body weight (197 vs 218; P < .01). Resolution of major comorbidities, complication rates, 30-day postoperative mortality, and postoperative compliance with follow-up were similar in the two groups. CONCLUSIONS: The data demonstrate that insurance-mandated PDC is an obstacle to patient access for surgical treatment of severe obesity and has no impact on weight loss outcome or postsurgical compliance. PDC should be abandoned by the insurance industry. (©) 2006 American Society for Bariatric Surgery.

[Jodi_620 37]

I agree with thininside. Let your surgeons office deal with them, they probably have an insurance coordinator that knows best on how to handle this. If coverage is possible, they would be the ones to find the way.

[CapitolChick 1]

too many friggn hoops with my insurance company too (then they ended up only covering RNY GB:thumbdown:)

I decided to do a payment plan and self pay using carecredit.com:thumbup:

I figure people buy cars on credit and this is to save my life.

if I had to to do all that cr@p just to get the help I need..my luck would be that the insurance company would stop covering it right before I got to the finish line.

I feel for you. Just reading all those RIDICULOUS requirements makes my stomach hurt...insurance comps. suck.:thumbup:

[Booklady 0]

You are worrying TOO much! Make an appt. with your doctor and they will handle all of that for you. You probably have history with a few doctors that have documented these things - you just can't think of them right now. It might takea month or two for all the materials to be gathered, but it will be worth the time and effort. I am a new bandster! Only one week into it, but I am getting better everyday.

[wstone 0]

I also have Great West and was approved for Lap Band. I was banded Thursday July 10. I had to get my MD to send them 5 years of my medical records. I also had to provide proof of a weight management for 6 months. Luckly I had been going to Weight Watchers so I gave them a copy of my bank statement showing proof of payment to WW. I also gave them a letter from Lifetime Fitness as proof that I had been on an exercise plan for 6 months. I believe that is all I gave them . I think one thing that helped me get approved was because I have a hernia that needs to be repaired and I also need to loose some weight in order to have Breast Reconstruction from breast cancer. My Breast Cancer Surgeon sent in my medical records and I was approved as medical necessity.

I hope that helps.

Waynette

[dolly_lala 0]

i know this can be very overwelming i'm in the same position as you, the best thing for you to do, is go to your primary doctor, and from there he or she will help you out if they feel you need the surgery, my primary has me starting the 6 month diet just incase i need it for aproval, he also recommended me to a surgeon, its quite helpful to have your primary backing you up in your journey....good luck

[MiamiChick1532 0]

Well that's just the thing...I have not been to a doctor in about 5 years. Last time I went was to my GYN and that was about 2 years ago. Im not going to Primary, Im going straight to the Surgeon. Anyway, I sent the info the insurance sent me to the DC's office and the lady told me she was going to review it and call me back. I'll you guys know what happens as I have my appointment on July 24th.

[bamamine 0]

Any time I tell someone I am thinking about lap band all I hear is, Oh they dont work. Or you will just be sick, you know you can still over eat. I dont hear anything good or positive. Why is that? Its like no one wants me to be happy.

[MiamiChick1532 0]

B,

I've heard and read the very same thing, until I found this forum. Obviously it has work for soooo many people here. For me this is the only option since I dont want to the the GastroBypass and still people who have done that still gain weight like that girl from Wilson Phillips so at this point I think it depends on you. I dont want to deal with what comes with the GBY. I rather bust my butt a bit more and get banded. Im miserable being fat I dont go out bc im to embarrassed I work and come home thats my life and I dont want it to be anymore. I feel like Im not me right now and that deep down inside there is a person who is confident, happy and outgoing. Someone who's dying to come out and do all those things I want to do like going out, going to the beach or a pool. I dont do any of that and i think is time i live my life instead of letting life go by. I just hope my insurance doesnt give me any bs about this because I dont know what am I going to do.

I was just as confused as you are but I started reading everything in here and I see sooooooo many people have lost weight and look and feel happy. If you feel the GBY is better for you do it but do what makes you happy. Being fat is not being happy at least Im not.

[Kat817 19]

What your insurance describes is the standard 6 month medically supervised diet program that many require.

If they deny you on that basis, you will need to find a PCP, and begin working the program for 6 months. And follow the details to a T! If it says monthly check ins, do not let it go to 32 days! If they want details charted, make sure your MD knows that, and includes the needed info in the chart.

Back when I was trying to get my insurance to cover mine, it was a 12 month required program......

Kat

[vegasgirl44 0]

Any time I tell someone I am thinking about lap band all I hear is, Oh they dont work. Or you will just be sick, you know you can still over eat. I dont hear anything good or positive. Why is that? Its like no one wants me to be happy.

bamamine, that is the very reason that I'm not telling anybody except for a select few who I know will be supportive. I waffle on decisions something awful. The band is the one thing in my whole life that I've been so sure about. I didn't want anybody screwing it up for me. When they start saying stuff to you about how you've been losing weight and how are you doing it, just say, like I'm going to, that I've been on a high Protein diet. That's it. And stick to this forum and your local support group. Good luck! We are all here for each other.