First Bump in the Road

Debutantex · 11-18-2005, 02:54 PM

I've already hit a bump in the road and I just started! Good grief. This whole process is NOT going to be fun and I can already tell. So, first thing I did this morning was call up my insurance company and ask them about LAP-BAND^®. My parents pay for the insurance we have [Anthem BC/BS] because they weren't satisfied with the insurance that is offered at their work places. So I get out my insurance card and call the customer service number on the back. The first guy told me that they didn't offer the surgery at all for the plan we are on because it's an individual plan instead of a group plan. Had we been on the group plan, then the surgery would be offered. So, that sucked. But for some reason it didn't get me down, so I went to class, took my test, and as soon as I got back out I called back again to ask. My rationale was the BC/BS is one of the biggest insurance companies in this part of the USA and surely they offered coverage for this surgery. It's not some home town locally owned firm - it's a huge company. So this time I talked to an older lady that was MUCH nicer than the man I talked to before. She searched and it said the same thing. No coverage for obesity surgeries. However, she said that to her it didn't sound right, so she made a call to the specialist for the company and they said that they would consider covering the surgery if my doctor can testify that I have medical conditions that are caused by my obesity and the surgery was necessary.

::siiiiigh:: I don't know if that's possible. I have a doctor's appointment on the 19th of December and I was actually supposed to go a long time ago. Ironically, I didn't go to the appointment back this summer because I was at the same weight I was last year when she told me to lose weight. I had really high blood pressure last Christmas [160/90] and she told me that the weight needed to come off or else I was putting myself at risk for a heart attack or a stroke. Eeek. It scared me for a little bit and I lost some weight, juuuuuust to gain it all back again. ::another siiiiiigh:: Do you think that my doctor could use my high blood pressure as a "medical condition" that is caused by my weight? I don't think I have diabetes [even though I get light headed and sleepy after I eat as of lately], and I really can't think of any other medical condition that I would have in order to present to the insurance company.

So I called my mom to tell her what they said and she asked how much it would cost to pay out of pocket - I had no clue, so I called the doctor that I'm considering and they said 18K to pay out of pocket. That's when I lost it and broke down crying. I wouldn't want to ask my parents to pay that kind of money for this because I'd feel bad.

I don't know what to do. I've lost weight so many times in my life and it all just comes crashing back to me. I know this is going to be a repeated cycle for the rest of my life and I just want to get this done now instead of 10 years from now. I just want to feel confident and beautiful, and I just can't do that when I'm 100 pounds overweight. I just feel so helpless. :( I'm already getting discouraged and I guess I got my hopes up that this was going to happen for me, and it just looks like it's not going to. And I don't know what to do about it...

Any suggestions or words of advice would be appreciated. Thanks.

Tricia K. · 11-18-2005, 03:25 PM

I'm sorry to hear that you're going through such a hard time with this. If I were you, I would suck it up and go to the doctor and discuss your concerns/express your desires and see if he/she will work with you to provide the insurance company with enough evidence that this procedure is medically necessary. I do believe that high blood pressure is considered a co-morbitity.

Good luck!

GeezerSue · 11-18-2005, 03:30 PM

A few things...

1--you can get insurance for anything...but the more a policy covers, the more it costs. People have BC/BS policies that pay and other people have policies that don't. You need to get a copy of YOUR policy and see what YOUR policy covers. It can be very different from the BC/BS policy the person next door has. And you'll seldom get the same answer twice from the people who work there. (Some just read better than others.)

2--a lot of what gets covered and what doesn't is in how you phrase it. My insurance is NOT in the mood to pay for a breast lift. But if WILL pay for a breast reduction and, if what is left of my breasts turns out to be lifted....well, oh my. If you ask for wls, you probably won't get it. If you ask for weight loss surgery because you're overweight, you probably won't get it. BUT, if you ask for weight loss surgery as treatment for morbid obesity, then you're at least in the ballpark.

3--your BMI is close. Most insurers want a BMI of 40. So if you are 5'9" and 265, your BMI is 39.1 and you are NOT MO. But if you are 5'8" and 265, your BMI is 40.3 and you ARE MO. So wear your heaviest jeans and several layers of clothes and, if they measure your height, have them do it while your shoes are off. Also, some insurers accept a BMI of 35 WITH comorbidities. Do you have any health problems related to your weight. (Do you snore? Have you had a sleep study?)

Then, I'm going to kind of give you a hard time here: You need to read more. My answers might be right or they might be way out in left field. When you pop into an internet bulletin board and ask a question, your answers could be coming from two drunks and an inmate with nothing better to do. Get information from several sources, and don't trust any ONE source to be 100% accurate all of the time.

Good luck,

Sue

banded_for_life · 11-18-2005, 03:35 PM

Drunkenly replying to Sue's remark, "I resemble that remark." *hiccup* :-) No really Sue is giving you some great advice here.

Dutchgrl59 · 11-18-2005, 03:36 PM

Hang in there, Rome wasn't built in a day. Keep that December appointment and start a journal. This is where your story begins. One day, after all this experience you will be able to give a hand to the newbie that writes about the "bump in the road" and you will have something wise and wonderful to share. Keep your chin up!
Hugs,

Debutantex · 11-18-2005, 04:02 PM

Thanks all :) I knew this wasn't going to be easy, because I knew it was going to be me writing lots of letters, seeing lots of doctors, and fighting lots of battles, but I certainly didn't expect to be kicked down right off the start. To say that my insurance company doesn't even OFFER the surgery really sucks. But there is that loop hole, and I'm going to talk to my doctor. In the meantime I'm just going to prepare for the worst and hope for the best. I'm going to try to get an appointment for this Tuesday, but I have to call back to ask if there are any cancellations that I can take their spot. So, cross your fingers that I can get in sooner. I really don't want to have to sit around and wait for the next month to see if there is anything that can be done about this. I need to know now so I can find something else to do.

I'm not very patient.

As for reading up - I have, plenty. I've ready dozens of different sites and message boards on the Internet. Everything that I could possibly get my hands on, I read. So hopefully I'm pretty well informed about the surgery - however, I'm certainly no expert and I'll continue to ask questions about it. A lot of the sites I visit don't target my specific questions that I might have.

So, we'll see. I may skip my classes on Tuesday so I can come home early to go to my appointment. It'll be excused with a doctor's note, so it shouldn't be a problem. As long as I let the professor's know in advance, then they shouldn't count it against me. I really would like to know the outcome of this.

If this doesn't work out, then I'm prepared to put my nose in the grindstone and bust my ass to lose weight. The only problem is, it's so hard to keep it off. It would be so much better for me in the long run to do the band, but if it doesn't happen, then it doesn't happen and it just wasn't meant to me. So, cross your fingers for me, and thank you all for your support :)

Road Queen · 11-18-2005, 04:07 PM

although insurance didn't cover mine, I am preparing my physician's letter for recommending surgery so I can deduct it off taxes. I have included high blood pressure, family history of overweight and diabetes, foot problems, etc. Read the co-morbidities listed on some sights and identify if you have them now or are even at risk because of excess weight, family history, etc.

Debutantex · 11-18-2005, 04:11 PM

That's something to think about [writing it off my parent's taxes]. Definitely something to consider.

Oh yes, and I forgot to mention. I was curious as to how tall I was because I've never been measured, I just always gestimated 5'9 - well, I'm actually 5'8 which makes my BMI over 40. At least I have that going on my side...

doubletrouble · 11-18-2005, 04:23 PM

I had bc/bc and mine was covered. My surgeon used a baraitric center and they have people that understand the insurance inside and out. They told me all of the rings of fire I had to jump threw first and then they submitted all of my information. It took one application and 6 days and I was accepted. Call your surgeon that you want to use and ask them what to do. Remember if there is a will there is a way. If you can not ge the answers you are looking for try another doctor. Also call your insurnace company for a copy of your coverage. PS A friend that I work with applied to bc/bs after my surgery and they now want everyone to see a doctor for 18 months prior for documented weight loss attempts. I understand that all bc/bs is different. Also if you have to pay out of pocket they usually have payment plans. Good Luck :>

**Alexandra** · 11-18-2005, 05:32 PM

Quote:

To say that my insurance company doesn't even OFFER the surgery really sucks. But there is that loop hole, and I'm going to talk to my doctor.

Sue is right, you're not asking the right questions. It's not your insurance carrier's job to "offer" medical care. You and your doctor make your medical decisions; your insurer's only decision is whether they will pay for it. If your contract says that treatment for morbid obesity is covered (not just "obesity") then you are already well ahead of the game.

Proving medical necessity is not a "loophole." Your doctor will have to make the case that your health depends on losing weight--and if your BMI is over 40 that will be a very easy case to make. THEN he has to make the case that LAP-BAND^® surgery is, in his judgment, the best treatment for you. If he's done other band surgeries and gotten insurance approval for them in the past, he'll know how to phrase his request. But you also have to write a letter and make a case that other treatments have failed in the past and explain why you believe this particular treatment is necessary. Get a letter from your primary care doctor as well.

What state are you in? It's also a very good idea to contact your state department of insurance to find out what your rights are with regard to appealing your insurance carrier's decisions. It doesn't matter what happens with other Blue Cross organizations around the country, they have nothing whatsoever to do with you. And your plan, as an individual plan, may indeed have very different contract provisions than those of group policies.

But don't give up! You are just beginning and must stay positive. We're here for ya!