[MIMMS1967]

Hi, I am new to this website and I am at the point of giving up. My dr's office has sent a pre-op request for both LapBand and Gastric Bypass and I was denied for both. The LapBand was "experimental" and in order for me to get bypass I need to have hypertension, diabetes. I don't have either, I mean my blood pressure is high but not considered hypertension. Does anyone out there have any suggestions? I have hit rock bottom and am now really really depressed.

[DocSanae]

Welcome to the board, thank you for joining us.
I hope you'll take the time out to check out this board, you might find info to help you.

Is this your first denial? Then don't give up!!! It is very rare to get approval with your very first application, for most people, it takes at least 2-3 time, some even more.
Have you checked out with your insurance co yourself, what the covrage for your particular contract is, and the criteria for surgery? This is about yourself, do not leave it up to the drs, you must start things rolling yourself.

The basic guidelines insurance cos go by is the NIH criteria of BMI over 40 being candidate for surgery without co-morbidities, or excess weight of over 80lb for women, 100lb for men.

Have you checked out the Insurance Book by CraigT who hosts this site?

MsVickie has a lot of posts up on insurance and how it works, so check out her posts, too.

Hope this all will help you.

((((((HUGS))))) May your journey go well.

[fr1endly2]

WELCOME to the board!
I would appeal the decsions and try to fight!
THEY dont always make this journy easy the insurance
companies but i would fight it as much as you can.
HANG in there i know it can be frustrating but i have seen
a few appeal the decisions and then win!

GOOD LUCK
and i look forward to getting to know you thru your posts

[MIMMS1967]

Thanks you guys! It gives me hope that I can turn my life around. I have been contacting past physicians, friends, and family to write letters on my behalf on how this surgery would help my life and how it affects my life living with obesity. I have found appeal letters online and am composing one. The surgeon's office told me yesterday that I don't need to do that because the insurance company only wants info from physicians. I am still going to submit my info to the insurance company and see if they will look at it.

[MIMMS1967]

Another question...does anybody know anything about AmerBen iinsurance? or dealt with them? they're based out of Colorado and Idaho, my husband's plan is under Ensign, United States Drilling Company.

[Kenyar]

Hmmm. I would contact the insurance company directly to see if they cover each procedure at all. Some insurance companies (or the plans provided) consider this cosmetic, regardless of the criteria and requirements. Start with that. Call them or go to their website. You might be jumping thru hoops for nothing.

I wish you the best of luck. All or most of us have been there at some point. Please keep your chin up.

[fr1endly2]

I will say that the package my surgeon prepared for my surgery was documentation from all the doctors that wanted me to have the surgery
....pulmonary specialist, cardiologists, nutritionists, my primary doctor, pscy. docs...all that was submitted and probably is what made the approval easier.
GOOD LUCK!

[MsVickie]

Hi Mim Im Vickie. First thing if I was Bill Gates I would buy all the insurance companys up and have my way with them LOL. Ok honey what im gonna do is ask you short questions wait for you reply and just try to guide you from there OK?

When you said your Drs office submitted the request.....Did you mean your Surgeons office? Or your family Dr? If this was the surgeons office did you get all your records from every Dr that you have seen in the last 5 years?

The other thing i will ask is which Insurance company pays first when you go to the Dr. The AmerBen or the Ensign?

[MIMMS1967]

My surgeon's office is the one that submitted everything so far. Here's what the policy says:

Expenses for treatment, supplies, instruction or activities for weight reduction, weight control, weight loss programs or physical fitness even if the services are performed or prescribed by a physician. Obesity in itself is not considered an illness or disease and benefits are not allowed soley for its evaluation and treatment.

Benefits will be allowed for obesity when a surgical procedure is required due to morbid obesity. Benefits will not be authorized unless:

a. the condition of morbid obesity has existed for at least 5 years; and
b. non-surgical methods of accomplishing weight reduction have been tried under physician supervision for at least 3 years; and
c. conditons such as high blood pressure, pulmonary insufficiency (lung disease), arteriosclerosis (hardening of the arteries), diabetes, coronary artery disease, and the like indicate a need for surgery.

Benefits will not be provided for subsequent procedures to correct further injury or illness resulting from the participant's noncompliance with prescribed medical treatment.


so, I have A and B but not diagnosed with C. Last night I was reading some of my medical records to track stuff and noticed that a doctor noted hypertension in 99. my blood pressure has ranged from 120/99, 142/88, and the other day it was 138/90. so is this something that I could point out to them??? Ms. Vickie I'm not sure of how to answer your question about the insurance. Ensign is my hubby's employer and Ameriben is the insurance co.

[MsVickie]

OK Mimms. I thought I read that you had 2 different policy's. So you just have one insurance.

I mistook what you said then. The high blood pressure thing is something that you family Dr. should have noted. Are you seeing the same DR as in 1999?

I would have someone you know or work with take you blood pressure daily. Take that list to your family Dr's office and show him. When your first Dx with Hypertension most Dr's will ask you to do this anyways. I think you will find that your family Dr will help you fight for this more than anyone.

I would tell the family Dr what your up against as far as this insurance. I do know that if you were going into surgery with your bottom number being over 90 they would cancel it. Or we do.

Im glad you have found out about if you had the benefit for this. I do think you could get around it even if your not Dx with Hypertension. Your BMI is over 40. Your more than 100 lbs overweight.

You need to remember this OK. The surgeons office submits records. They get a denial or approval. If its denied its up to YOU not them to get it approved. They will submit anything you give to them to submit if they think it might help.

Like for instance your policy has something different than I have seen before as far as criteria. Like Arteriosclerosis and Lung Disease.

Do you have Asthma? That will serve as lung disease.
Have your Dr reevaluate your for Hypertension.

I find it ridiculous that insurance company's ask for what they do.

I do agree with the BMI being over 40 and being at least 100 lbs overweight.

Get moving on the hypertension thing and let me know how its going. You have to fight for this....... no body else will.