Questions for all that have been banded or are in the process

So I called my insurance company again and they told me that the procedure would need to be deemed medically necessary by my doctor. Has anyone had any expereince with HUMANA? Do they make you try other things first? To be honest with you besides a family history (mom, aunt, and grandmother being obese plus a dad with high colestrol) I have not had any other medical problems. I am just now starting to have sleep apnea (I think) and also knee problems. I am only 26 years old. Based on what I have found being 5'1" and 230 pounds I am MORBIDLY Obese. Do you think that I can qualify with just that? Is it hard for the doctor to convince the insurance co? I have my 2 hour consult coming up soon. :O) I feel that I need this as I have tried everything to loose and just can not. :O(

I have a feeling they will not cover your surgery being you have no other "co-morbitites" such as High blood pressure, diabetes, things of that nature. It is VERY hard to get insurances to pay for this surgery. I just went self pay as it is much easier that way. Good Luck in your journey!

I have no experience with Humana, but can give you an overall idea of what I have seen required here on the site.

Most will require you to show a 5 year history of obesity---which you can do with any Dr. records that show your weight. You could have gone in with allergies, if they weighed you, it is documented---and will work.

Most require a set BMI. Average is 40 with no co morbidities, and 35 with. Co morbidities being high blood pressure, sleep apnea, diabetes, joint problems, high cholesterol, etc.

Some require a time (6 months to some a year) of medically supervised weight loss attempts. You will be required to see a Dr. each month, and consult often times with a nutriotionist. Some do not require this at all.

You can call the number on the back of your insurance card, and they can tell you what the requirements for your particular plan are. They should be more detailed than saying it has to be deemed medically necessary---they should have guidelines stating what falls in that category. Keep in mind, that someone elses experience with Humana may not be the same as yours it all depends upon the policy your employer bought. Some employers do not cover WLS even if the insurance company offers it.
Once you find out what is required you can begin gathering things to submit. Some allow you to send photos, or letters on how this would improve your life, how strong the familial patterns are etc.

If they don't give you any other information, I would get a package together to present to my Dr. so he could see it IS a medical necessity. Take candid photos, detail what each family member has wrong due to obesity. Show what all diets you have tried. Consider adding how your weight has crept up through the years, and anything you can come up with to make your point. Stress the fact that you are currently morbidly obese, and how that restricts your ability to obtain life insurance, and how it lessens your abilities to advance in your job....

Sell yourself!

Go to your consult, hit a seminar or 2, study up on the surgery, it is not the easy way out. It does make the way out easier though! Be VERY prepared, so when your Dr, asks you questions, you can answer them with knowledge. The more you know going in, the better off you will do!

Good Luck! And welcome to LBT!
Kat

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No fill + Steroids + Stress = 34 pounds to lose AGAIN!!!






Love People and Use Things, Don't Use People and Love Things.....

Kat gave you some good information. Definitely call your insurance provider and ask them for specific qualifications around BMI, comorbidities, etc.

IME, it was very easy to go through insurance, and definitely worth it. Even if it had been more of a struggle, my total surgery bill including psych visits was something like $80. So yeah, if you don't have exclusions, it's stupid to not try.

I had a morbidly obese BMI, but did not have any comorbidities. Ok, so I have a torn ligament in my knee and could have claimed knee pain, but I didn't (I'm one of those honest types). Cholesterol was good, BP was good, no unfounded aches or pains, no mobility issues, etc. I *assumed* I would have to do a supervised diet or some other tests, but nope. Basically, I filled out my surgeon's paperwork, provided 5 years' worth of medical history (which amounted to 6 visits: 5 annual physicals and one visit not related to weight), and that was it. I expected to have this long drawn-out battle, but 3 weeks later my surgeon's office called me and told me I was approved, and the letter came from my provider the next day.

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-175 pounds
Banded March 1, 2006

Starting? You are now starting? Hmmm.... you've had that knee/joint pain for a while now, right? CHRONIC

Do you wake tired? Sure you do! Others have told you that you snore, right? Possible SLEEP APNEA

All the times you've been to the doctor, you can recall times your blood pressure was up, right? High Blood Pressure

These are just a few examples. There is NO CHECKLIST to qualify for the band, however, there are guidelines. You can definetly go to INAMED's site for the LAP-BAND®, read up and recognize anything....anything that pertains to you.
When you go in to see your doc, use those words and phrases in your discussion.
Your doc will be your best ally when it comes to getting insurance to pay.

Good luck!

My stats are similiar to yours and I am with Humana and it was covered. I did find out recently though that it was coverd because my employer accepted it.

Good luck.

Wow! Who was your insurance carrier???

The insurance company could cover this procedure. It will depend on what your BMI is. If it's over 40 you could be a prime canidate.

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Band Date: Oct 30, 2007
Dr Touliatos - Trinity Medical Center
Birmingham, AL

UHC. I picked them specifically because my research indicated they would be my best bet to have the procedure covered. I was in a lucky spot of having decided to have the surgery right around the same time that I accepted a different job offer, so coming into my benefits selection I had something like 17 new choices, and picked the one I thought would be most band friendly. :)

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-175 pounds
Banded March 1, 2006

According to what you said with your weight and height your BMI is 43.5 plus you have co morbs, so if they do cover the band you should be included.

If your BMI is under 35 w/o co morbs then they won't consider it 35-40 with co morbs they consider 40 and above sometimes all you need is your BMI.

Good luck

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Dianne

Dr Voellinger
Charlotte NC
Surgery 9/25/05 1.7cc
Starting at 268 well on my way to 160!
I plan to continue to feel good!
The band was Gods plan for my life, so I know I will succeed even when troubles come my way.

Hi from TX. I have been through a 4 year battle with my insurance. I have seen multiple doctors and have had them write letters directly to the insurance company as well as to my Husbands work. I have demonstrated a long history of dieting, exercise, high blood pressure, diabetes, high cholesterol, joint pain and a BMI ranging from 35 - 40. Nothing worked. In the mean time I was saving like crazy and finally went self pay. I am very happy to have had the procedure and just don't care about how much it was. I know it will take along time to repay my loan, but I just can't put a price on the benefits of having this surgery. I am very very happy and it has only been one week since surgery. wishing you the best.

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banded: Jan. 08 08 by Dr. Vuong, Houston
H 310/S 232/ C 190/G 145