New and need advice please

October 21, 2005

Im 27 years old. 5'3 259 pounds. My BMI is 46.

Ive been researching lapband for a few months, finally decided to call my insurance to see if it was covered, and was given some wrong information.

Long story short, my doctor has given me the thumbs up for surgery, but now insurance is telling me something different than they originally told me.

Other than joint pain (back, hips, knees) I have no other signs other than obesity. My labs are fine, Im not diabetic, and my blood pressure is perfect.

I have an old back injury from 4 years ago thats aggravated by weight, I see this as my only "in" to getting insurance to cover it.

Im a CNA, and caring for people is my passion, Im not about to change careers because of my weight problems.

Any advice you can give me for other things to include in my appeal to my insurance for coverage would be GREATLY appreciated!

Ive been overweight for almost 20 years. Ive tried it all...diet and exercise, WW, Atkins, South Beach, etc. I can lose about 40 pounds and then I just stop losing. And with the low(er) carb diets, I get sick after about 4 months.

ReneBean · October 21, 2005

So, call the insurance company AGAIN. Specify that you are trying to determine if they cover "surgical treatment for morbid obesity".

I had to fight this with my insurance company, too. They told me they did cover it - I got all the pre-testing done - and THEN they told me they did NOT cover it... It was an error.

Also - check your company policy - because even if your insurer covers treatment, your employer may have a specific exclusion for bariatric surgery.

Even if you find that there is no specific exclusion and your insurer covers it - they will probably deny you the first time - on general principal. Be prepared to make and appeal. (I am waiting for mine to be reviewed, right now.)

For more info - read all the threads in the insurance forum - from the top down.

I'm keeping my fingers crossed for both of us.

:]

mousecrazy · October 21, 2005

Hang in there...and keep asking questions. These insurance companies count on people taking their first answer....ask again.

I was BMI 45, no comorbidities besides joint pain, like you. My insurance co. covered the surgery at 70%. All insurance companies are different, and if there is not an exclusion, you may well be in luck! Cindy

chichigirl · October 21, 2005

Have you had any trouble with shortness of breath upon exertion? Do you wake up frequently during the night, then feel sluggish all day long? If you answered yes to either of these questions, you may be suffering from weight related dyspnea or sleep apnea, both of which are obviously weight related. No one had ever checked me for it until recently. I was sent for a sleep study and I found out that I indeed suffer from sleep apnea. So now I sleep with a CPAP machine and mask. Another thing you may want to consider is having the new heart scan that's being done. It's a 64 slice CT scan that is now being called the best diagnostic tool for determining the health of a woman's heart. It shows early plaque, both soft and hard, as well as any hardening of the arteries. I don't know how old you are, but I was only 38 when I had a heart attack and needed a quadruple bypass. I too had normal blood pressure when it happened. Also have you had your cholesterol and triglycerides checked, just a simple blood test, but also considered to be obesity related problems. If you have any gynecological issues, such as irregular menstrual cycles, this too can be obesity related. I ended up with endometrial cancer at age 39 and was told it was due to my weight. Fat stores estrogen and the type of cancer I had was estorgen sensitve, as are certain breast cancers.

I know I have thrown a lot at you, but just thought you'd want to know all of this so you can possibly use it to fight the insurance company. I know I didn't realize that a lot of the problems I suffered from were weight related until it was too late.

Good luck,

Cindy