new to LAP-BAND® Maryland or Delaware

spalm · 01-15-2006, 02:58 AM

Hi everyone!! This seems to be a good support group. I am hoping to get to know you all and to eventually be able to give information to someone new like myself to help get started and to give my support. Everyone here seems to be a big supporter of each other and sticks together. Thats AWESOME.
I am new to ALL of this LAP-BAND® stuff. I have for a couple of months just read some posts on this site and have been playing with the idea of getting it done for myself. I know its a long process but am wondering if someone would be so kind as to tell me where to start. I believe I have enough ailments. To many to mention right now. I do know that I should fit in the catagory with the BMI of over 40. I have over 100+ lbs to lose.
I have BCBS of Delaware. Does anyone know what you have to do about getting your insurance to cover it? I have heard some post say its no problem to have BCBS cover this procedure and other post say they wont at all because the procedure is experimental.
First off I have looked into some Doctors

Dr Schweitzer in John Hopkins in Baltimore, MD
Dr. von Ruedon in Baltimore.

Dr. Ingau in Delaware

1. WHERE do I BEGIN?
2.Where is the best place to get research on this? to tell me the steps I need to take to begin
3. Does anyone know what the success rate is with these doctors?
4.Has anyone had to deal with BCBS of Delaware to get this procedure covered?

If anyone can help I would appreciate it. If you need to you can email me direct. Thank you.

stockymd · 01-15-2006, 10:42 AM

Spalm,

First of all...welcome to the board and your new journey :clap2: .

:welcome:

My first suggestion above all others would be to call your insurance company and ask them if YOUR policy covers LAP-BAND®. You can not always go by what others experience is with the same insurance because some employers may purchase a cheater version of the plan.

When speaking with the insurance company ask for the name of the person you speak with on every instance. Ask them what is required for approval.....they will no doubt be reading from a list of some sort. Ask that the criteria be mailed to you in writting.

Depending on what they require, i.e., 6 month supervised diet etc. You will want to begin that at once by meeting with your PCP every month and following some sort of diet provided by your Dr. In my case my PCP refeerred me to a nutritionist who I visited once a month as well.

Dr. S I hear is awsome just has a long waiting period...If you are interested in him...If you have not done so already call to get an appointment, as this will usually be a 5-6 month wait. Don't know his stats but his office will tell you if you call.

Great places for research are sites this this as well as http://www.obesityhelp.com http://.annualsofsurgery.com www.obesityresearch.org www.nejm.org www.newsrx.com

This is one article
http://www.mja.com.au/public/issues/183_06_190905/obr10369_fm.html
This is were people have given their opinion on their banding experience
http://www.remedyfind.com/rm-3919-Gastric.asp

Hope this helps you get started.....Good luck and hope to meet you.

Cristina:brushteeth:

spalm · 01-15-2006, 11:28 AM

Hi Cristina, Thanks for the information. I believe I have a long road ahead of me with the insurance.

My husband works for a union in Delaware. I looked at his policy book last nite and anything related to weightloss whether recommended by your doctor is NOT covered. I was told that I would need to appeal to the board of Trustees to try to even approve this procedure since the insurance is a self pay through the union and like you said many may have the same insurance but some employers may purchase a cheater version of the plan.

Anyone else have this same experience that could give me a sample appeal letter.
I know they have approved different cases for infertility even though any type of infertility treatment is also NOT covered but you need to write a letter and in some case they have been known to provide some type of coverage.

It so frustrating when you pay for the insurance but yet they decide what they want to cover and to make exceptions for whoever but I am not going to give up. I dont know how many letters I can write but I am prepared to keep fighting (strong word) it. Thanks

stockymd · 01-15-2006, 11:53 AM

I wish you the best and I'm glad to hear you are willing to fight for better health for yourself.

One thought...you mentioned your insurance does not cover "weightloss". I have heard of instances where the insurance will have an exclusion for weightloss or the like...but leagally they can not exclude tx for morbid obesity, which is what you are seeking.

There are samples for appeal letters on the obesityhelp site. Also a good book to buy is weighloss surgery for dummies. There is a great appeal letter sample in there, as well as lost of great info about this whole process.

spalm · 01-15-2006, 12:35 PM

I am not only trying to fight for myself but after suffering from PCOS and having fertility issues we have a 15 year old son and now have a 10 month little girl who I want to be able to enjoy life with her instead of being on the couch in pain and watching. It really is depressing!! I am 40 years old and hope I have many years left. Yup I am over the hill!! LOL
ahhhh a loop hole is it??. Actually it says in my plan book:

services and/or drugs in any way related to weight reduction, whether or not recommended by a physician

Whats your take on that? It sounds to me any kind of treatment but if my doc puts morbidly obese than maybe??? I am going to call tommorow and see what my insurance actually says before I contact my husbands local union.

stockymd · 01-15-2006, 06:37 PM

I'm no expert on the language of your policy. However, that statement sounds like your insurance will not cover visits to a nutritionist for weight loss (as opposed to visits for diabetes for example), nor would it cover prescription drugs for wieght loss. That is fairly common for all insurances...since there are over the counter drugs for "weight loss". I would call and get an answer from them directly. When you get one answer call again the next day to see if you get the same answer. Some reps are more informed then others. Keep us posted.

spalm · 01-15-2006, 07:57 PM

No I know they wont cover them because when I was pregnant I had gestational diabetes and the nutritionist that I had to see was not covered. Luckily I controlled it with my diet of low carb and didnt have to go back. my gyn watched it and I monitored with the glucose monitor. but... I think that would be worth paying for if the insurance did cover the procedure.
I will definitely call in the morning and will keep everyone posted. Hopefully help someone else also..

LSasha · 01-17-2006, 08:50 AM

:welcomeB: Spalm:cheer2:

spalm · 01-17-2006, 09:06 AM

Hi everyone,
I just wante to follow up and tell you what I found out. So it is encouraging for others if they are in the same situation.
I called BCBS of Delaware this morning. I was told that my insurance does not cover anything that is diagnosed for obesity. Also, my husband policy at work states what I mentioned above.
When I told the rep that my primary doc is suggesting that I have LAP-BAND® surgery. Thats its not just for weightloss although that would be nice but for health issues she put me on hold for awhile and came back with these conditions.
She did say that these are not a guarantee of benifit coverage until my doc calls the referall center and everything has to be precertified even though my insurance does not requirie me to get pre authorized. I guess this case is totally different. She also said that it doesnt say in her list but she does know that get a cardiac clearance and a pshy evaluations is also required. But this is the qualifications that she said:

1. covered if medically necessay
2. attempted and failed at some sort of weightloss for 1 year. She said conservative measure for one year. Does not have to be the past year. (I asked if it had to be for 2005.)
3. have 1 of these:
hypertension
a BMI of over 35 for more than a year but must be at least 40 now
sleep apnea
Type II Diabetes
Degenerative Joint Disease
coronary arteries
100 + overweight

I know I have been reading some post that your insurance will tell you one thing and then at the last minute they'll throw someting else in there. They didnt mention about seeing a nutrtitionist for 6 months. So I am actually expecting to hear that needs to be done also. It would be nice to post what some may have had to do before being approved so others can jump ahead. Hope this helps someone.
I guess the biggest thing is even though my husbands benefits say no to weight reduction even if recommended by a doctor - that may not always be so cut and dry so its still worth it for anyone to look into. So crossing my fingers.....
If anyone knows of something else the insurance has been known to throw in there please let me know. Thanks

Carebear22803 · 01-17-2006, 11:12 PM

Good luck with everything! Keep us posted-

spalm · 01-20-2006, 08:53 PM

Well heres an update- I went to my PCP and he said he would write a letter and do what he could do to get the insurance to approve the surgery.

Well, I wanted to get better clarification on my policy. Even though I was told that BSBS would cover the surgery if the above cirteria that I wrote earlier was met. Well thats true but..... with the exlusion that my husband has on his policy at his job stating anything weight loss related will not be covered even if recommended by a doctore the surgery will not be covered. BCBS call my husbands Employee Relations office to clarify it for me. Then I called and was told which I had heard before. If the Insurance is self pay through the union then whatever they have in their health benefit policy over rides what BSBS says. So a team of trustees decide your future even though your doctor says its medically necessary. Crazy or what??? Anyone have any suggestions?