[dee deee]

HELPPPPPPPPPPPPPPP!!!! I'm trying to get approved by my insurance. I have no support from my pcp. He is telling me that they wont approve me because being obese is not enough. i lose weight very well i just cant keep it off. I have lost 170 pounds with weight watchers and gained 120 back. I would like lap band to help me maintain. Does anyone have a similar story?

[kitcatcopycat]

Get another PCP ..I know it hard to start over but you need some one that will listen to you. I am not saying change in insurance just change your dr within your insurance plan. Make them listen. Also call your insurance company & see what their requirements. Then youwill know what you aredealing with.

[dee deee]

Originally Posted by kitcatcopycat

Get another PCP ..I know it hard to start over but you need some one that will listen to you. I am not saying change in insurance just change your dr within your insurance plan. Make them listen. Also call your insurance company & see what their requirements. Then youwill know what you aredealing with.

Thank you, I have contacted the insurance and they are really tough, i knew that. $25k for surgery is not going to be handed to me. I have to go to a nutrionist for 6 months. How much weight should i lose? And if i do lose weight will they say no to surgery because i can do it with out it? i just cant keep it off. i have been fighting this fight my whole life, and have been obese 90% of it. I am a food addict, i feel surgery will help me fight my addiction .

[kitcatcopycat]

The 6 month program is to help you prepare for the surgery. They need to have on file that you tried all conventional methods & failed. In addition this a life altering surgery. You need to start to be healthy now even if you do not lose any weight before surgery. my insurance company did not require any weight loss before surgery. But I did lose 21 lbs just be replacing a meal or two with a protein shake (as per my surgeons recommendations). You are going to still have to eat health & exercise after surgery. Starting the life style now will be easier on yiou after you have your surgery.

[MyTurn2009]

First of all, I would not bother with the PCP, unless you need that referral to go to a bariatric surgeon in the first place. Find yourself a good surgeon in your area. They usually have programs all set up to work with you. I told my PCP after I had my first appoinment with the surgeon. (I was lucky that my insurance did not require a referral from him first, although I think he would have given it to me). What I did have to provide the surgeon was a documented 5 year weight loss history, which I made the PCP's office send to them. The surgeons office took care of everything else that was required. They know what the various insurance requirements are. If your insurance does require a referral, I would pursue that with the PCP until you get what you want. Tell him/her that you want another opinion. I see you are in Connecticut. So am I. If you want to, private message me and maybe I can give you more pointers.
Nancy

[MyTurn2009]

By the way, your BMI should be right around 40, according to the stats you filled out. Most insurance programs will qualify if BMI is 40 or above, or if BMI is between 35-40 if you have co-morbidities. So, I would think you just might qualify.
Nancy

[majhx4]

I'd do their 6 month nutrition guide but just not actually do it. That way you will not lose weight on it. Because if you lose weight you will lower your BMI.

I am like you - I could lose weight even with conventional methods, I just couldn't keep it off.

[kaytijo]

I agree, go to a center of excellence seminar start working with the surgeons office. They will help you get everything you need for approval, if it is a 6 mo diet they will have the Nutritionist work with you for 6 months. Really all that is monthly weigh ins and diet, I lost about 40 during the first 4-6 months during mine, but gained it all back just a few months later and I just got my approval today!

Let the actual surgeon decide if you are the right canadite or not, not your PCP.

[kitcatcopycat]

Ladies - Unless you have a PPO, most if not all HMO's will require a referral. The surgeons have to follow the 'insurance guidelines' unless you pay out of pocket. Yes for the most part surgeons will know what they need to submit to the insurnace company. But this does not mean you have to sit around & wait to find out what happens next. Calling your insurance company, being an informed patient is to your advantage. Surgeons have hundreds if not thousands of patients. You can & will get lost in the shuffle.

If you have a HMO & need a referral, your PCP can make or break your referral to the surgeons office.

The surgeon decides whether or not he wants you as a patient, but in the end it is the insurances decision, not the surgeon's. The surgeon gives the insurance your information when submitting for approval. The surgeon follows the guidelines of the insurance company. They will not and can not start cutting until the insurance approves. If the insurance company say's no, then you have to appeal with the insurance company not with the surgeon. In the end it is the insurance company, not the surgeon that makes the decision. Unless you pay out of pocket.

If you pay out of pocket you will still have to qualify. Every surgeon & insurance company has different qualitifcations. No set rule.