Anyone Out There Have Pacificare (HMO)?

kat72 · 08-28-2005, 04:44 PM

I just wanted to know if anyone with Pacificare (HMO) has had the LAP-BAND^® surgery approved through this insurance. I called them and was told that only the RNY and the vertical banding are covered. I was just wondering if anyone has been successful in having them cover the band even though they say they do not.

08-29-2005, 11:13 PM

I am wondering the same thing... let me know if you find out!!

**Jack** · 08-30-2005, 12:01 AM

I have Pacificare in Oregon. I had watched the coverage on-again the off-again for several years. Last year 2004---they announced the Band would be covered for that year, but dropped for 2005. I had surgery 12/21/04.

Further, I had to find a way to get 'out of network' approval since the local surgeon only did RNYs....

THAT was an interesting experience...and if y'all sign up for my little seminar....

I feel fortunate to have slipped in when I did...although it took about 18 months to get it all set up....

Be aware of what specific benefits your policy actually covers....and what hoops it takes to utilize them....

HMOs are like a restaurant having a wonderful menu...but then the waiter announces if you're actually going to eat then the kitchen is closed....

kat72 · 08-31-2005, 12:07 AM

Jack, thanx so much for the info. you've provided. I've been told by the insurance co. as well as Don Mills that I could have the surgeon recommend that I have the LAP-BAND^® and it is possible that it could be covered, but who knows? At this point I have not been able to get any other info. from the ins. co. concerning the LAP-BAND^®. They only cover RNY and vertcal banding. I am so confused, because if I can't get the LAP-BAND^®, then I will not be able to have weight loss surgery, because I am not big on all of the risks that are involved with RNY. If you have access to anyone else that I can speak to in Pacificare, please let me know. Thanx!

**Jack** · 08-31-2005, 12:20 AM

re: "I could have the surgeon recommend that I have the LAP-BAND^® and it is possible that it could be covered, but who knows?"

THIS IS CRITICAL!!

It is your personal physician...in my case an internist....along with support from an orthopedist...who helped point out the were several layers of contraindications because of my co-morbidities, that the open RNY was TOO HIGH A RISK....

As I understand it....at the time LAP-BAND^® WAS covered but my local facility didn't have the set-up to do it....so I HAD to be referred "out of panel".....which was to a hospital 100 miles away...

It is NOT the carrier's job to tell you WHO can do WHAT if ANYTHING to you...remember that...

they CAN tell you WHAT they will pay for....which is another issue...

I got in contact with a HMO nurse who actually was very helpful in walking thru several steps. She was a sort of 'patient ombudsman' who clarified what the carrier really needed and what steps I had to complete to satisfy those procedures. I was totally surprised at how helpful she was. Her job seemed to be 'patient care oriented' rather than 'case management oriented' if you get the difference.

keep working at this....there sometimes are ways...what state are you in? And dig out your members benefit booklet...it will tell you in clear terms.... you have to find the specific paragraph that states these procedures...In the end, there just may be a specific exclusion on LB. I can't help if that is the case, but there are attorneys I'm sure who specialize in just such situations.

Whether you choose to have LAP-BAND^® is NOT up to the carrier....it is up to YOU and your doctor....who pays for it may be the real issue....and IF you come to a decision, 'who pays' of considerable less importance in the long run.

Keep us posted.

kat72 · 09-01-2005, 06:47 PM

Jack, I live in San Diego, Ca. I do not have my members benefit book, but I sure requested that it be mailed to me a few days ago, so hopefully, it will be here any day now. Thanx so much for the info., and I will definitely keep you posted.:)