Hi gang!

I'm anticipating that I'm going to be denied by my insurance (Tricare Prime) because they consider lapbands to be "investigational". Naturally, I'm keeping my fingers crosses anyway that they've come to their senses.

However, I want to be prepared for an appeal. I'd really appreciate any links that people have bookmarked to studies showing the long term effectiveness of the band vs RNY (which Tricare would happily pay for me to have done if I didn't mind the risks and having my insides rearranged!). I'm thinking about studies showing long term results vs RNY, risks of lapband vs RNY, and any other studies preferably published in medical journals that show the advantages of lapbands vs other options.

Now I'm not blind to the fact that lapbands also have their downsides and risks. I just think my chances are still better with the band. I absolutely will not consider RNY or DS (both of which the surgeon I've been working with is very skilled at doing and strongly prefers to the lapband....and yes, I'm considering other surgeons too. I think he's more than skilled, but may still be on the learning curve for lapbands since he has only done about 20.)

I'm basically trying to change the policy of a government vendor. Not an easy task! I do plan to ask Imamed for help. I also think especially given the recent news coverage, that I'll contact my Senators and Congressmen and ask for intervention on my behalf. Trust me, a Congressman's office phoning the insurance company or the AF surgeon general's office probably has a little more impact than just my appeal letter!

Anything else you all can think of that might help with an appeal is greatly appreciated.

Always

Hunzi

preparing to tilt windmills

In the October 2005 issue of the "Journal of the American College of Surgeons" is an article by a group in Georgia that has performed over 1000 Bands.

http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T91-4GTW92Y-4&_user=10&_coverDate=10%2F31%2F2005&_rdoc=1&_fmt=summary&_orig=browse&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=c2f254ffea7d3c1eeafe02ce49c89872

The abstract is free and you can buy the entire article for $30.

Thanks Doc.

Yep, that one was so good I used it in my insurance appeal. Hope it works!

Hunzi, I had other references that I posted in the insurance sticky thread and If you would like to see my letter, I will be happy to e-mail it to you.

:]

Hunzi, would you be willing to share the info that you gather? I was banded about 2 weeks ago, but my sister is about to have bypass (in March). She'd rather get banded, but like you her insurance said that they will pay for the bypass but not the band. I'd really like for her to try and appeal it and any info would be useful.

Thanks,

Benet

Thanks y'all!

Every little bit helps.

Always

Hunzi

Call Inamed and ask for Don Mills, he has a wonderful file that he will email you. It has loads of information on band vs bypass. That helped me win my appeal. ~Mandy

Thanks everyone! I'm going to hang in there for a while and see if a miracle occurs and I get approved. If not, thanks to everyone here, I should be able to at least write a darned good appeal. Whether that makes a difference or not, who knows. If the answer is still no, I'll drop back to plans B, C, and D: waiting for them to come to their senses, going on my DH's healthplan at work if I find out they cover it, or saving my pennies and flying to Mexico.

It may take me a few years of extra determination, but I will get banded!

Always

Hunzi

hey hunzi,

i am tricare prime and thinking about dropping down to standard to pay the 20% and be done with it...please please please forward me any information you get as i will be in the boat battling w/you quite soon!

thanks!!!

Why would you drop down to standard...are you sure it's covered?

I just went from Prime to Standard (because my surgeon only accepted Standard), had my pre-surgery appts. and am now waiting to hear what Tricare says. My BMI is low at 36.7, but I have co-morbidities so....we shall see.

They told me in the surgeon's office that Medicare stepped up to the plate and started covering lap-band in Feb. and whatever Medicare does, Tricare follows. I have my fingers crossed.

Just this morning I checked mytricare.com and my referral to see a WL surgeon has been approved. The funny thing is it is for a Dr that only does Lap Band. Until today I had never considered a Lap Band and I don't know much about it. I can not call the Dr or TRICARE until Monday so I am trying to research as much as I can

I have TRICARE PRIME REMOTE, I am wondering if this means they are going to start paying for Lap Band????

Medicare does cover the band, but only in what they call A Center Of Excellence. This is tough to find in a lot of places and limits the hospitals that are equipped to do the surgery. A Center Of Excellence would be a full-service, five-star hospital that does open heart surgery for one. It would also be a hospital that has done thousands of lap bands and RNY's. If Tricare follows Medicare and makes that ruling, it could be tough. A lot of surgeons are not doing the lap banding for Medicare patients because they are with smaller hospitals that have not been approved and may never be approved. In my case I'm going to my daughter's in Tennessee to go to Vanderbilt which is a Center Of Excellence. Please make sure and google this before proceeding with your choice of physician/city and make sure you have one of these Centers or be prepared to travel to one. I wish you the best of luck. I have a friend who has Tricare. They approved her for bypass when she wanted the lapband; she fought them but she didn't win; and she had the bypass. She's had lots of problems that don't come with the band, but the band has a different set of problems for some and for others it seems they have few problems.

Tricare pays for plastic surgery one time after your weight loss, which is a great thing, but this is on RNY. I'm curious if anyone on here had Tricare and fought and won to have the lapband. Maybe if you are tenatious as a bulldog you can get them to do it.