http://www.lapbandtalk.com/ For discussion of issues related to Insurance coverage and financing of lap-band surgery. en Fri, 20 Nov 2009 22:00:53 GMT vBulletin 60 http://www.lapbandtalk.com/images/styles/lapband/misc/rss.jpg http://www.lapbandtalk.com/ http://www.lapbandtalk.com/f8/does-medicaid-pay-100-a-105853-new/ Fri, 20 Nov 2009 18:20:17 GMT ok i know medicaid cover my surgery and all my appointments except the nutritionist but do they pay 100 percent of it all only some of it? ok i know medicaid cover my surgery and all my appointments except the nutritionist but do they pay 100 percent of it all only some of it? ]]> nightgangl7 http://www.lapbandtalk.com/f8/does-medicaid-pay-100-a-105853/ http://www.lapbandtalk.com/f8/aetna-help-105838-new/ Fri, 20 Nov 2009 14:58:04 GMT My doctor does not know how to evidence the years of obesity. Please help! What does the insurance require? Is there a particular format? Does anyone have sample templates? My doctor does not know how to evidence the years of obesity. Please help! What does the insurance require? Is there a particular format? Does anyone have sample templates? ]]> ocharles http://www.lapbandtalk.com/f8/aetna-help-105838/ http://www.lapbandtalk.com/f8/omg-good-news-last-also-jargon-help-105818-new/ Fri, 20 Nov 2009 01:58:15 GMT :thumbup: So after 7 years... yes... seven YEARS... without insurance that will cover this, I finally got a county job with amazing BCBS coverage that includes WLS! I had to work VERY hard to contain myself and not do a happy dance on the table in front of me- including some very funny moves-... :thumbup:

So after 7 years... yes... seven YEARS... without insurance that will cover this, I finally got a county job with amazing BCBS coverage that includes WLS! I had to work VERY hard to contain myself and not do a happy dance on the table in front of me- including some very funny moves- in employee orientation when I saw the line for Bariatric Surgery!

Because of their policy, my benefits don't kick in until the first day of the month following a full calendar month after my first day. A whole lot of fancy words to say I started in November, add a month puts it in December, then the next first day is January 1st. New Year. New chance! Couldn't be more perfect!

http://www.napebt.com/summaries/2009_medical_ppo_500_summary.pdf
Here is the paper I'm referring to for the following questions:

So since I'm new to having insurance I have to pay something other than copay up front for, can someone help me figure this out? It says, "$1,000 access fee, 80%/20% after meeting deductible." It says my maximum coinsurance is $3,000,and elsewhere in the booklet it says that the 20% coinsurance is based on their allowable amount, not the amount of the bill. And I've heard the allowable amount is lower because insurance companies don't want to pay as much as the hospital bills, and the hospitals are happy to get paid anything so they go along with it. Is this right? And I have a $250 deductible. Does this mean that I would end up paying the $250 deductible, the $1,000 access fee, and $3,000 max out-of-pocket co-insurance, bringing my total to $4,250? Are there other costs associated with this that I don't know about? I want to know as much as I can up front.

I can't call the insurance reps and talk to them about it yet because I am not insured yet, so they can't look up the policy. At least that was my experience with my last insurance company. And the HR rep said it'd be the same case here.

So anyone have experience here? Any words of wisdom? Thanks so much for reading! ]]> wendy645 http://www.lapbandtalk.com/f8/omg-good-news-last-also-jargon-help-105818/ http://www.lapbandtalk.com/f8/insurance-revisions-105817-new/ Fri, 20 Nov 2009 01:49:27 GMT I wanted to know if anyone had any luck with insurance approvals on revisions, specifically those that do not include removal of the band. I'm asking because I have AETNA POS and they approved my revision but when I went in for surgery all the surgeon could do was remove it. They plan on trying to do the revision later. Will I have to apply again? Do the diet all over again? I'm confused, especially since it was too difficult to do both at the same time. ]]> mrlddst http://www.lapbandtalk.com/f8/insurance-revisions-105817/ http://www.lapbandtalk.com/f8/insurance-financing-105732-new/ Wed, 18 Nov 2009 17:47:48 GMT Anyone have Hardvard Pilgrim Navigator and any issues getting approved? Any answers would be appreciated. Thank you! Anyone have Hardvard Pilgrim Navigator and any issues getting approved? Any answers would be appreciated.
Thank you! ]]> manseaud http://www.lapbandtalk.com/f8/insurance-financing-105732/ http://www.lapbandtalk.com/f8/approved-last-105690-new/ Tue, 17 Nov 2009 22:27:02 GMT I just got a call from Kelley at Obesity Law and Advocacy Center or obesitylaw.com telling me that she was just faxed my approval from BCBS IL. My employer has an plan exclusion on weight loss surgery, so this was a difficult process and has taken close to two years. I was denied twice by BCBS IL...
I just got a call from Kelley at Obesity Law and Advocacy Center or obesitylaw.com telling me that she was just faxed my approval from BCBS IL. My employer has an plan exclusion on weight loss surgery, so this was a difficult process and has taken close to two years. I was denied twice by BCBS IL and obesitylaw.com was denied once before finally approved. I am very excited and ready to make the necessary changes to start my new life.

I truly appreciate all the support and encouragement I have received from all of you at this forum, and I can say without hesitation that I will have many more questions for you in the future. Thanks for being there for me.

Dan
]]> GoneFishin http://www.lapbandtalk.com/f8/approved-last-105690/ http://www.lapbandtalk.com/f8/empire-bcbs-ppo-105624-new/ Mon, 16 Nov 2009 18:36:48 GMT Does anyone have Empire BC/BS PPO and willing to share what the process was like getting approved? I am at the very begining of what I am sure is a long process and have no idea what I am in for as far as the insurance is concerned. Thanks!! Heather Does anyone have Empire BC/BS PPO and willing to share what the process was like getting approved?
I am at the very begining of what I am sure is a long process and have no idea what I am in for as far as the insurance is concerned.
Thanks!!
Heather ]]> hlubag http://www.lapbandtalk.com/f8/empire-bcbs-ppo-105624/ http://www.lapbandtalk.com/f8/insurance-financing-australia-105605-new/ Mon, 16 Nov 2009 14:34:22 GMT Hi what are my options in Australia, mum was telling me today that medicare might be covering it, I know there is finance for surgery's these day and i have even heard that you can use your super because its considered life saving surgery, can anyone back any of these? thanks:smile2::smile2: ]]> reece86 http://www.lapbandtalk.com/f8/insurance-financing-australia-105605/ http://www.lapbandtalk.com/f8/beware-exact-coverage-aetna-105467-new/ Fri, 13 Nov 2009 17:35:52 GMT My surgery was Oct 8th. I followed 3 mo. plan required w/Aetna.
I"m just now seeing figures on my Aetna acct online for expenses.

They're still denying the psych consult costs because now they said I needed a preapproval thru ANOTHER company.

There was nothing in any papers, phone conversations, medical plan booklets, etc that said I needed preapproval thru another source for psych consult.I dont know how they expected me to pull the name & number out of the air as to who I was supposed to get approval thru. I read what was sent to me regarding requirements for weight loss surgery. It tells what is required in order to have the surgery but does NOT mention they dont pay for nutrition or psych consults.
To be honest, the drs office told me their cost would cover all of my medical expenses & requirements for the sugery. My mistake for not getting what "all costs" were in writing.
I'm lookin at a bill of over $500 but I'll appeal/fight it if/when it's denied. ]]> WhyW8 http://www.lapbandtalk.com/f8/beware-exact-coverage-aetna-105467/ http://www.lapbandtalk.com/f8/proposed-changes-tricare-coverage-105442-new/ Fri, 13 Nov 2009 03:39:58 GMT Tricare is proposing new regulations in regards to LAP-BAND® and other weightloss surgeries. This is a good thing. They want to use BMI as a means by which to assess acceptance rather than just "100 pounds over weight". Until December 28th they are requesting comments for this change. All you have to do is go to
Regulations.gov and then click submit comment towards the center of the page to leave your thoughts. You don't have to give all the address and govt agency info unless you just want to, that's just voluntary extra stuff.

For more info on the topic check out page 14 of the November 16th edition of the Navy Times. It's in the section titled FastTrack. ]]> lsullivan68 http://www.lapbandtalk.com/f8/proposed-changes-tricare-coverage-105442/ http://www.lapbandtalk.com/f8/tricare-prime-approval-105420-new/ Thu, 12 Nov 2009 22:40:57 GMT Hey so i went to the doc on Monday and she put in my refferal to get the lap band. I know its only been 4 days but im iching to get things going. Im 200% over my ideal weight, High calisteral, high tyroid, and pre diabetic. I dont think i will be denied i just wondered how long it normally takes... Hey so i went to the doc on Monday and she put in my refferal to get the lap band. I know its only been 4 days but im iching to get things going. Im 200% over my ideal weight, High calisteral, high tyroid, and pre diabetic. I dont think i will be denied i just wondered how long it normally takes for them to approve it. ]]> meginsf http://www.lapbandtalk.com/f8/tricare-prime-approval-105420/ http://www.lapbandtalk.com/f8/im-approved-105416-new/ Thu, 12 Nov 2009 22:11:07 GMT Finally! After 2 + years and literally 100's of pages of weight watchers logs, monthly physician reviews, etc.... I'm approved. BCBS denied me three times - I wore them out I'm sure. Yay me!!

Now what? I was so caught up in the fight I forgot what's next - how funny. ]]> Northern Mist http://www.lapbandtalk.com/f8/im-approved-105416/ http://www.lapbandtalk.com/f8/how-long-did-take-your-ins-approve-105407-new/ Thu, 12 Nov 2009 20:19:57 GMT My info was submitted 3 weeks ago and I'm just wondering how long did it take to hear from your insurance? I know they said it could take a couple of months, but I'm so eager to find out. I just pray that I am approved! ]]> TracyW2 http://www.lapbandtalk.com/f8/how-long-did-take-your-ins-approve-105407/ http://www.lapbandtalk.com/f8/cigna-6-month-period-105389-new/ Thu, 12 Nov 2009 15:00:12 GMT Hey there. My name is Megen and I have insurance through Cigna. I am in month 2 in the 6 month program, and I was just wondering what everyone submitted for insurance approval. I have read the criteria for the lapband several times, and called the 1-800 number a few times also, but I was... Hey there. My name is Megen and I have insurance through Cigna. I am in month 2 in the 6 month program, and I was just wondering what everyone submitted for insurance approval. I have read the criteria for the lapband several times, and called the 1-800 number a few times also, but I was wondering if I could hear some firsthand experiences with getting approved. I am tracking everything I eat for the 6 month program (although I haven’t lost any weight- actually gained 8lbs), I am tracking every time I work out, and I am making all the necessary appointments for the letters of medical necessary. Also, I am aware that CIGNA covers 90% of the cost for the lap band, but I also would like to know what the typical out-of-pocket cost was. Thanks! ]]> megkpik http://www.lapbandtalk.com/f8/cigna-6-month-period-105389/ http://www.lapbandtalk.com/f8/chaning-doctors-after-being-approved-105377-new/ Thu, 12 Nov 2009 06:46:03 GMT I am wondering if I can still have my surgery if I change doctors. I have tricare prime(south) but have moved to Virginia which is tricare (north); since I have been approved in the south can I just find a new doctor and not have to go through everything again? Or should I just go ahead and have... I am wondering if I can still have my surgery if I change doctors. I have tricare prime(south) but have moved to Virginia which is tricare (north); since I have been approved in the south can I just find a new doctor and not have to go through everything again? Or should I just go ahead and have surgery in South and find doctor to fill in the North? ]]> delta27 http://www.lapbandtalk.com/f8/chaning-doctors-after-being-approved-105377/ http://www.lapbandtalk.com/f8/insurance-financing-105318-new/ Wed, 11 Nov 2009 14:24:57 GMT Anyone in MA have experience with Harvard Pilgrim Navigagtor insurance?? Have my first appointment with MD in December! Thanks!:smile: Anyone in MA have experience with Harvard Pilgrim Navigagtor insurance?? Have my first appointment with MD in December!

Thanks!:smile: ]]> manseaud http://www.lapbandtalk.com/f8/insurance-financing-105318/ http://www.lapbandtalk.com/f8/tricare-approvals-105182-new/ Sun, 08 Nov 2009 22:43:30 GMT Hi, I was just wondering what your experience with Tricare has been? I am 5'3 and 229 BMI 40. I do have arthritis in my one ankle, have degenerative disc disease in my neck and am pre-diabetic. Just wondering what you think about my chances for approval? I also am considered disabled through the VA (I am a vet, for migraines, and my arthritis, etc). I am also tricare standard (best decision I ever made in regards to doctor choices) I am near St Louis now

Thanks for your help. Are you glad you got it or are getting it?

Heidi
heidshosh@aol.com ]]> heidsz http://www.lapbandtalk.com/f8/tricare-approvals-105182/ http://www.lapbandtalk.com/f8/anthem-blue-cross-blue-shield-ohio-ppo-105080-new/ Fri, 06 Nov 2009 03:13:52 GMT Just wondering if anyone else has this & if so how hard was it to get approved? ]]> kidmiester73 http://www.lapbandtalk.com/f8/anthem-blue-cross-blue-shield-ohio-ppo-105080/ http://www.lapbandtalk.com/f8/anthem-bc-bs-ohio-ppo-105078-new/ Fri, 06 Nov 2009 03:11:03 GMT Just wondering if anyone else has this & if so how hard was it to get approved? ]]> kidmiester73 http://www.lapbandtalk.com/f8/anthem-bc-bs-ohio-ppo-105078/ http://www.lapbandtalk.com/f8/hip-medicaid-105048-new/ Thu, 05 Nov 2009 18:23:17 GMT hello i was wondering if anyone eles has hip medicaid and if you do what was the process like of getting lapband ? what i mean is what do they make you do such as all the tests and how hard is it to get approved basicaly all the info you got is great lol thanks hello i was wondering if anyone eles has hip medicaid and if you do what was the process like of getting lapband ? what i mean is what do they make you do such as all the tests and how hard is it to get approved basicaly all the info you got is great lol
thanks ]]> nightgangl7 http://www.lapbandtalk.com/f8/hip-medicaid-105048/ http://www.lapbandtalk.com/f8/medicare-texas-104786-new/ Sat, 31 Oct 2009 19:39:24 GMT I am curious what entails and how long it takes before I can actually schedule a date for surgery with medicare. I am on disability. I have been doing a supervised diet with my DR. Will I have to also do another one with the bariatric surgeon? I have no idea what happens and am looking for some... I am curious what entails and how long it takes before I can actually schedule a date for surgery with medicare. I am on disability. I have been doing a supervised diet with my DR. Will I have to also do another one with the bariatric surgeon? I have no idea what happens and am looking for some input. Thank you. ]]> sandralee http://www.lapbandtalk.com/f8/medicare-texas-104786/ http://www.lapbandtalk.com/f8/insurance-wont-review-file-help-104758-new/ Sat, 31 Oct 2009 00:16:18 GMT I have been working on my file since beginning of September and it was finally submitted to BCBS TX 10/22. Today they informed me that they won't even review my file regardless of my multiple comorbidities due to exclusion. My Dr. said they will appeal and they are positive I will win on approval. However, the Insurance company states nothing will change their decision. I have been fighting my weight forever, so waiting won't change much. But am I fighting a battle with them that I can't win? Any help or information is much appreciated.

WAITING.......:confused: ]]> Makes_Pretty_Babies http://www.lapbandtalk.com/f8/insurance-wont-review-file-help-104758/ http://www.lapbandtalk.com/f8/uhc-state-employee-az-104691-new/ Thu, 29 Oct 2009 21:30:05 GMT Hello everyone!
I'm calling the insurance company next week but wanted to see if anyone here has some experience with the United Health Care coverage for AZ State employees? When I looked into LapBand in 2008, they required 5 years med history, 6 month supervised diet, BMI over 40 or over 35 w/2 comorbidities. They just changed coverage this year and was just wondering if anyone knows if this is has changed? :confused: I appreciate your help!

Thanks! ]]> MandaPanda http://www.lapbandtalk.com/f8/uhc-state-employee-az-104691/ http://www.lapbandtalk.com/f8/help-writing-appeal-letter-104674-new/ Thu, 29 Oct 2009 17:22:46 GMT I need help writing an appeal letter to Tricare;
When my information was first submitted; I weighed 219.5 and am 5'6". It was denied.
My doctor resubmitted my information on my frame size which is small and my new weight of 228.5; I gained weight after having surgery on my leg and being off for 6 months.

Anyway, I am now according to Tricare over 100 pounds and I have HBP, diabetes, infertility, hight cholesterol, arthritis, acid reflux.

Where do I start? What do I say? If you have any examples you can send them to delta27@earthlink.net or attach them to an email on here to me.
Thanks ]]> delta27 http://www.lapbandtalk.com/f8/help-writing-appeal-letter-104674/ http://www.lapbandtalk.com/f8/so-upset-anthem-104614-new/ Wed, 28 Oct 2009 23:27:00 GMT Hi everyone, I am so upset. I had my surgery on Thursday 10/22 and it was scheduled for outpatient meaning I could stay in the hospital if it was less than 24 hrs. I had waited almost a month for the drs office and the hospital to agree to outpatient only. The hospital used to not allow lb... Hi everyone,
I am so upset. I had my surgery on Thursday 10/22 and it was scheduled for outpatient meaning I could stay in the hospital if it was less than 24 hrs. I had waited almost a month for the drs office and the hospital to agree to outpatient only. The hospital used to not allow lb procedure as an outpatient. My drs office said they finally agreed to do outpatient procedures as of Oct 1. Well my lb procedure took longer and the surgeon had to repair a severe hiatal hernia, and do a liver biopsy. I endured terrible pain, nausea, vomiting, etc while I was in the hospital the whole time but they let me go and I had been on the unit for maybe 22 hrs.
When I was released to go home I told the nurse I was ready to leave and she said not to worry I was just in observance and not using all the 24 hrs.

Anyway when I got home today my insurance carrier sent me some standard form letter saying I was denied inpatient and they only approved outpatient. I called them and they said someone called the next day to get me inpatient status which this letter is saying they denied.
I told the rep I was outpatient the whole time and she said if that was the case then it would be paid. But this letter said my inpatient status was denied.

Has this happened to anyone else? I am so upset. Of course the hospital and the surgeons office was closed by this time.
Please give me any advice and send your prayers and good thoughts my way. I am trying not to flip out. I feel this letter has shortened my life by a few years since I got so upset when I read it...
Thanks for reading.:confused: ]]> Tory09 http://www.lapbandtalk.com/f8/so-upset-anthem-104614/ http://www.lapbandtalk.com/f8/anthem-requirements-104605-new/ Wed, 28 Oct 2009 20:31:18 GMT Has anyone had to have a 6 month diet? Pre op Surgeon Consulataion? Psych Eval? Nurt Eval? If so how long did it take for approval after submitting the paperwork? Thanks:tongue: Has anyone had to have a 6 month diet?
Pre op Surgeon Consulataion?
Psych Eval?
Nurt Eval?

If so how long did it take for approval after submitting the paperwork?

Thanks:tongue: ]]> Sallen1107 http://www.lapbandtalk.com/f8/anthem-requirements-104605/ http://www.lapbandtalk.com/f8/anthem-ca-104593-new/ Wed, 28 Oct 2009 17:16:59 GMT Does anyone know what the requirements are for them?:tongue: Does anyone know what the requirements are for them?:tongue: ]]> Sallen1107 http://www.lapbandtalk.com/f8/anthem-ca-104593/ http://www.lapbandtalk.com/f8/pre-approval-testing-hold-until-jan-1-a-104482-new/ Mon, 26 Oct 2009 20:25:24 GMT Here's the thing....I just saw my surgeon for the first time last week. I haven't even decided if I want this surgery...but have decided to go ahead with the approval process. I would be looking at a Mar-May surgery date if I decide to proceed.

However, the Dr.'s office has already scheduled me (this week) for things like EKG, sleep study, chest xrays, etc. They assured me these things were a copay situation.

When I got to the hospital I was informed that they are a deductible situation. That is a big difference. I wasn't wild in the first place to have testing for an approval for an insurance that could change at renewals in December. But if it was just a copay - fine.

Now that it is a deductible...I put everything on hold until after Jan 1. There is no sense in me paying a $250-500 deductible with 8 weeks left in 2009 - when it is going to start over again in two months and I will have to pay it all again because the surgery is (theoretically) in 2010.

I am nervous this is going to irritate the Dr's office but if there is an urgency I am unaware of...they should be taking the time to explain it to me. She called me Friday with the Monday appts...and gave me incorrect payment instructions.

Just thought I'd vent.

Thanks! ]]> LTOT123 http://www.lapbandtalk.com/f8/pre-approval-testing-hold-until-jan-1-a-104482/ http://www.lapbandtalk.com/f8/insurance-said-yes-then-no-after-procedure-104445-new/ Mon, 26 Oct 2009 06:20:45 GMT I'm new to this forum, so please bare with me! I've had my realize band surgery on September 16 and the surgery went great. I was in and out of the surgery center in less than 3 hours. My doctor was great before hand and for the surgery. But my troubles started after the surgery. During my initial conversation with my Dr, I expressed concerns with regards to the cost. I was told that they will go through the process of verifying my insurance. I received an approval letter within a week. During my discussion with my dr, they assured me that my out of pocket expense should be approx. $4000 but it might go up to as high as $8000. I was okay with that. After the surgery, I never heard a word from my doctor. Not even a follow-up the day after. I had to call them to schedule my first fill - which was supposed to have taken place last week. In the mean time, I received the bills for the surgery and came to find out that my insurance isn't paying for about 90% of it. My dr's fee alone was $14,900, but the unbeknownst to me, he added the new doctor at his practice to my surgery as well. I essentially hired one doctor and was given two, for an additional $4000. The insurance only paid $900 of that. Then the real shocker came. The surgery center , where I was for 3 hours, which includes before, during and after surgery, charged a whopping $76,000. And the insurance is covering none of it. And this surgery center is the same place where on the day of the surgery, my doctor had 8 patients lined up for surgery that day. Talk about a cattle call. But needless to say, his surgery coordinator assured me that this was the best location and that insurance will most certainly cover this particular location. I'm so angry with my Dr & his staff that I opted to cancel my fill appointment, out of fear that they will hit me with another astronomical bill. So, I guess my question is, what do you do if your insurance says yes before and then no after the procedure when it comes to claims. And also, how do you suggest I handle the situation with my doctors' office? I feel like they deceived me on purpose by not telling me exactly how much each service would have cost, especially since I asked so many times prior to the surgery. I'm so disappointed in the whole experience, I still have no fill and I'm on the fast track to being bankrupt with a $100K bill. Any advice and/or suggestions?! ]]> FrustratedInLA http://www.lapbandtalk.com/f8/insurance-said-yes-then-no-after-procedure-104445/ http://www.lapbandtalk.com/f8/some-hope-insurance-denied-104373-new/ Sat, 24 Oct 2009 15:17:02 GMT I have been going back and forth with my insurance after my "denial" in August....after giving up for a little while and deciding to go South of the Border and "self pay".....I put down deposits, bought airline tickets and was prepared to do WHATEVER I had to do!!....

Then...it hit me....I AM SICK.....I have had a heart attack (at 30yrs due to migraine medication), I have high blood pressure, and horrible pitting edema and was being looked at for possible congestive heart failure...I am 35 years old.....

I decided I WOULD NOT let my insurance NOT help me....I called....dealt with a wonderful woman at my insurance company directly....had all 86 pages of my med hx resubmitted and ......I WAS APPROVED.....IN LESS THAN A DAY!!!

So...in short.....don't give up...fight your insurance...you pay for it....you deserve it!!!! ]]> Neener http://www.lapbandtalk.com/f8/some-hope-insurance-denied-104373/