Just starting to explore options...help!!!

Branso5111 -
The first thing I did was call my insurance company. They are the most knowledgeable about your policy besides yourself. Tell them specifically that you are considering gastric banding CPT CODE:43770. Ask them if 1)it is covered and 2) if it needs precertification/authorization and 3) if there is anything that needs to be done before authorization - that is - they may require a psych eval etc.. Make sure there has not been any break in coverage for at least the last 12+ months. If there is a break, they will make you wait until the anniversary of your policy because obesity then becomes a "pre-existing condition." I have an extremely restrictive policy and they "approved" me in 1 week with a lot of effort on my part and the fact that I had met all their conditions - psych eval, nutri eval etc..

You go girls! I was denied too, I have United Healthcare, but I appealed and sent a letter from my primary doctor which stated that I have high blood pressure and sleep apnea. Supposedly, if your BMI is under 40, they will cover the surgery if you have high blood pressure & sleep apnea. My advise - appeal, appeal, appeal!! :) I got my approval letter today! What a shock! I was getting ready to borrow the money and pay for it myself!! Best of luck to you!!!

Does anyone know if Medicare will pay for this surgery?

yes, it does. i am using this point to fight my insurance (who would not pay for my Lap Band). article attached.


http://www.bannerhealth.com/About+Us...s+Lap+Band.htm

Anyone have any advice my Insurance Co. wrote back and said I hadnt had a nutritional assessment or follow up plan I went to my dr for a Dr's weight program They wanted that so I thought that was good enough, I wnt for 8 weeks like they wanted, and they also said Lap Band is Experimental/Investigational Thanks for any advise anyone could give me.
Trish

Hi there, I was all set to go and met the criteria for Cigna. My company had switched insurance companies this summer from United and at the same time put a condition in not to cover any gastric surgery. Of course they said nothing to the employees and now I am out 300 dollars for my initial consult.Eve

My advice to anybody who is just starting out is to keep a notebook and document what you do everyday in it (towards getting this procedure done), ie: date, time, name of person you talked to, what they said, your ideas, phone and fax numbers, addresses, who you requested medical records from, and any other details. Because the insurance battle is very involved and there is no way to remember what all you have done, this is just an idea....to help keep organized and not confused....

I had trouble just getting the insurance company to say it was even covered: (this is supposed to be the easy part...ie...just finding out if it is even covered. )
1. I called Anthem ( my provider) on July 31st. The rep. told me the lap band was a covered procedure - I told her I looked everywhere in my policy and couldn't find where it stated it was or wasn't covered. She read me the verbage from my policy. I was very happy!
2. I filled out 30 pages of paperwork for a hospital in Ohio to have the procedure done.
3. I got a call from the hospital Monday (August 21,06) that they had called my insurance and it wasn't an approved procedure.
4. I called my insurance company on that Monday - this time they told me it wasn't an approved procedure. I explained that I called 3 weeks ago and I was told it was covered. The rep said she saw where it was recorded on my file that I called in July and told it was approved. She said there was also a call on August 18 where they told the hospital it wasn't approved.
5. I spoke w/ several reps that Monday and upon further investigation of my policy they discovered- in one section of my policy it states bariatric surgery is a covered benefit and then in another part of my policy it is also listed under exclusions as not being covered.
6. Hence, a 4 day ordeal began
7. No one seemed to know if it was covered or not and the supervisor wasn't sure so she had to forward it on to her supervisor.
8. I was supposed to recieve a call back and never did.
9. I called several Monday afternoon, Tuesday evening and
Wednesday evening and each time they told me there was no update.
10. Finally on Thursday, August 24th I called the insurance company. I spoke w/ a rep and explained the situation. She read me the notes on my file that were dated August 21 (the original day I called and was told it wasn't covered) that there was a note on my file saying "since bariatric surgery is a non-standard covered benefit on my policy - then I have that benefit. It doesn't matter what the exclusions say. The non-standard benefits always over rule"
11. So, I waited 4 days for nothing...and the process has been delayed about a week b/c of this issue.
12. I'm very happy that this is finally cleared up and the lap band is a covered procedure - now I just have to get approved.
CONCLUSION: Don't take no for an answer - especially if you know you are correct!
I wonder how many other people this has happened to?
I'm now waiting for the hospital to call me back so we can get the process started.

I hope everything works out for you in the long run. I'm in the process of trying to find a surgeon that will consider me through my doctor if only I can find the time in between school.

Samantha

P.S. Don't give up if this is what you want fight for it.

Brando, I can refer you to my doc... He charges as little as $7,300. I was banded 8/26/02.... Also, I had an erosion and was debanded 1/6/06 and now have the gastric sleeve.

I have an appointment tomorrow and I feel overwhelmed. The paper work asks for all this information I don't have. When I tried all the other weight loss things over many years, I never thought there was a reason to keep track of everything I did and document it all. I don't have high blood pressure, but I do have other problems. I am just so worried that I don't have enough information to get approved and I have a hard time even imagining what a finacial burden I would place on my family if we self pay. DO I even have half a chance at having my insurance cover me if I don't have documentation of everything I have tried? Ahhhhh! Thats how I am feeling right now.

Hi there! Received my denial from Regence BlueCross BlueShield of Oregon today. Lap band is exluded in which I new! I am trying to fight it. This is a portion of the letter they wrote...

We have reviewed your concerns and the information that you provided. Under your gruop contract, through (my employer), the treatment for obesity is specifically excluded from benefit payment, regardless of other medical condtions that may be related to or caused by obesity.

When a service, treatment or supply is not covered, under the contract, the member.patient is financially responsible for the non-covered service. Our denial of benefits is not based on the medical appropiateness of the requested surgery; it is based on the specific limitations of your contract. You may wish to pursue alternate means of financing for this procedure.

I regret that our findings could not be more positive. Let me advise you that, on a disputed determination, you are entitled to three levels of review. This grievence is the first level. You have the right to file an appeal with Regence BlueCross Blue Shield of Oregon. In case you wish to exercise your right to appeal. I have included a form for your use. Your appeal must be submitted within 180 days of this determination.

In the case of an adverse benefit determination you are entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevent to your claim for benefits. Additionally, you have the right to file a complaints or seek assistance with the Oregon Insurance Division by calling (503)947-7984 or writing to Oregon Insurance Division Consumer Protection Unit
350 Winter Street NE, Room 440-2 Salem, OR 97310 http//www.cbs.state.or.us/external/ins

Sheri Yuckert
Grievance Coordinater

Sooooooooooooo. What do you all think???? Do you think I am wasting my time trying to appeal it because it is excluded???

HELP! The doctors office charges $19,500 for Lap Band here in Portland Oregon. OUCH!

Kathy

re: "the treatment for obesity is specifically excluded from benefit payment, regardless of other medical condtions that may be related to or caused by obesity."

IMHO, it appears they have expressly excluded this type of benefit from your policy. I doubt there is a way to prevail under such circumstance. When one shops for coverage, with such a competative field of choices, attention to such details is essential.

Good luck.....there are other ways to obtain your choice of care, than by what the insurance carrier defines in their policy. Some people use home equity loans....there has to be a bunch of creative ways to finance out there.

Lots of trouble with mine but finaly got an approval it just takes a little time in some cases but most would say its worth the wait!

thanks for sharing that letter!

Kitty