Questions:Insurance and stuff

mschaffer66 · 01-08-2008, 01:47 PM

My wife and I have BCBS PPO. I'm 27 years old, I'm 5'10", and I weigh a touch over 300. My knees ache if I stand for too long and I have horrible back pain that I'm no longer able to rehab because I've gotten too fat to exercise and strengthen.

Is there any doubt in anyone's mind that insurance will cover the Lap Band. To be honest I think I will go through with it even if they don't.

Thanks in advance.

RoseNewLife · 01-08-2008, 03:26 PM

Hello msschaffer66,

My insurance is also BCBS PPO, and it is covering my Lap Band surgery. My General Practitioner had to fill out a form stating I had 2 conditions relating to my obesity (I have high blood pressure, and also bad knees) plus sign that she has documented other attempts at weight loss by me (weight loss attempts that failed - like weight watchers, etc.). My doctor was happy to help me in all of this. BCBS then covered the Lap Band procedure.

Good Luck! I hope everything works out for you, please keep in touch and let me know how you do!

RoseNewLife · 01-08-2008, 03:36 PM

Well, I should say my insurance *will* cover my surgery. It's coming up quickly! ;-)

Teachlady · 01-08-2008, 04:46 PM

Quote:

Originally Posted by RoseWolf

Hello msschaffer66,

My insurance is also BCBS PPO, and it is covering my Lap Band surgery. My General Practitioner had to fill out a form stating I had 2 conditions relating to my obesity (I have high blood pressure, and also bad knees) plus sign that she has documented other attempts at weight loss by me (weight loss attempts that failed - like weight watchers, etc.). My doctor was happy to help me in all of this. BCBS then covered the Lap Band procedure.

Good Luck! I hope everything works out for you, please keep in touch and let me know how you do!

Ditto this for me... Insurance covered it. I started the process in January of 07 and had surgery in April 07..could have had it sooner, but scheduling conflicts..

**Wheetsin** · 01-08-2008, 05:02 PM

There's really no way for us to say if your insurance company will cover you. It depends on the plan, the terms, exclusions, ammendments, etc.

BTW, I'm around 5'10, and weighed 382 when I had my surgery. And I was not too fat to exercise, so chances are that you are not either. :)

MamaJava · 01-08-2008, 08:42 PM

I agree that it totally depends on your individual plan, terms, etc.

I also have BCBS PPO (Gold). I HAD to have (no if's, and's or but's) 1 or more of the following:
A. Sleep Apnea
B. (severe) Diabetes
C. Heart issues

PLUS a BMI over 40
PLUS have more than 100 pounds to lose.

If I would not have had sleep apnea, I would not have been banded 4 days ago.

So not all BCBS PPO's are the same.

MamaJava · 01-08-2008, 08:49 PM

I should also add that none of my additional physical issues mattered at all to my insurance. They didn't care that I have obesity-induced joint deterioration (making it nearly impossible to exercise), hip displacements, severe edema or any of my other issues. They didn't care that I had been a Weight Watcher member over 11 times. They completely ignored my doc's 3-page custom-written letter pleading my case. They set all that paperwork aside and the first time I was denied they were like "this is all ya got?"

LOL it was right at that time that my sleep center called and said you need a CPAP like NOW...and I was almost immediately approved after BCBS got that documentation.

kirajh · 01-08-2008, 10:03 PM

I have BCBS but I don't know if it is a PPO or not. It is through Teamsters. For approval, you have to have a BMI of 40 or 35 with comorbidities. Letter from your doctor, letter from a surgeon and a psychological evaluation. I can't tell you how easy it was to get approved because I flunked the psych. evaluation so I didn't even submit it to insurance. Went to Mexico instead. The clinic I first went to said that BCBS required the supervised diet and were giving me a hard time cause mine didn't.

GOOD LUCK...............HOPE IT ALL WORKS OUT FOR YOU,

mschaffer66 · 01-09-2008, 06:19 AM

Thanks for all the info. I go in for my consultation next Tuesday. The only problem is I don't have any documented medical assisted weight loss programs. I've always tried to do it myself in the past. Other than suggesting things like what to eat and watching calories my doctor has never been helpful.

You are right, I'm not too heavy to exercise. But the weight in conjunction with my back and knee problems makes anything but walking hard. :( My hope is that by the time my banding day comes along I will have rested my back enough so I can slowly start exercising and building strength to get more intense.

babygrl1234 · 01-10-2008, 07:08 AM

Here is what I know from my minimal working experience with my surgeons office.
Starting this year BCBS will cover the surgery with no diet documentation if your BMI is over 50. Between 40 and 50 you need one year of doctor supervised diet attempts (4 visits per year) if your BMI is 35-40 you need the diet documantation and 2 comorbidities (sleep apnea, high blood pressure, etc).

Now this is just a general overview of BCBS, your individual policy will either cover the surgery or deny coverage.

mschaffer66 · 01-10-2008, 09:11 AM

I wish I had known some of this stuff years ago...I would have documented then. I guess we will see what kind of magic they can work. I've been seriously dieting since my second year in college after gaining a ton of weight my freshmen year. I've tried every diet under the sun. I even tried some weight loss drugs at one point that made my heart beat so fast it felt like it was vibrating.

Exercising and being active has never been the problem until I hurt my back. My problem is just eating in general. Its a horrible addiction. People say the hardest thing to do is to quit smoking...but at least your body doesn't need cigarettes, you won't starve to death if you don't smoke.

Sorry, I'm ranting.

From what I've seen the Lap Band will curtail my eating, which in conjuction with a healthy diet and limited exercise will help me shed some weight. After I get rid of some of the weight my back will actually be able to get better then I can crank up the exercise and really start making a difference. Is that a valid idea?

babygrl1234 · 01-10-2008, 09:36 AM

I understand exactly how you feel. definitely check out your policy. Worst case senario (assuming your policy does cover), you are a year away from surgery. It sounds bad but it is only a year. If you have been to any doctors in the last 3 years and the doctor told you to lose weight, you dicussed weight loss or dieting, get those office visit notes. You need 1 years worth in the last 3 years. If you have not been to the doctor than go asap and get your documentation going.

And yes you have the right idea about the band. It is a very useful tool but you will only get out of it whatever you put into it. It is not easy and it is hard work.

mschaffer66 · 01-10-2008, 09:41 AM

Quote:

Originally Posted by babygrl1234

I understand exactly how you feel. definitely check out your policy. Worst case senario (assuming your policy does cover), you are a year away from surgery. It sounds bad but it is only a year. If you have been to any doctors in the last 3 years and the doctor told you to lose weight, you dicussed weight loss or dieting, get those office visit notes. You need 1 years worth in the last 3 years. If you have not been to the doctor than go asap and get your documentation going.

Or I could swallow a few lead bars and get my BMI up to 50 :) haha

babygrl1234 · 01-10-2008, 09:57 AM

I think that would be an awful lot of lead =)

mschaffer66 · 01-10-2008, 10:03 AM

True...and it may cause more problems. :)