Any suggestions on how to fight my insurance company so they will pay for gastric lap-band surgery?

Question

I have decided that I would like to have gastric lap-band surgery. Over the past 15 years my weight has yo yo-ed and I cannot seem to maintain the weight I lose. Please refrain from lectures on healthy living, diet and exercise. I have heard it all and totally agree....I just can't seem to maintain those goals over a long period of time. Any suggestions on how to present a successful appeal to my insurance company that might compell them to cover the cost of this surgery?

I should mention that this surgery is not covered by my plan so I have not been denied, it is simply not covered by the plan my employer pays for. I was told by the company today that I could file an appeal now without having to go through the motions of filing insurance to then be denied.

Answer 1

If it's not a covered service, you can not force them to pay for it, no matter what.

What you can do is have your doctor (your regular MD) provide a letter of medical necessity, especially if you are grossy obese and this could save your life. (All insurances refuse to pay for it if you are less than 110 lbs overweight.) The insurance can then say yay or nay on it after reviewing this record.

Answer 2

Have you already been denied? If so, what were the reasons? You have to know the reasons so you can fight against them. If they deny because they don't deem it medically necessary then you need to provide documentation from every doctor you can get from the last 15 years to show you have tried and to list all the health issues you have. Even ones you may not think of such as depression due to your weight issues. Also write a personal letter explaining why you feel you need this surgery. Mention how hard your life is with the extra weight, etc. The more documentation you can provide the better. Especially if you have a lot of health issues. Most health issues such as diabetes, sleep apnea, high blood pressure, etc improve after losing major weight so they are more apt to pay when they realize you'll cost them less money in the long run. Good luck!

Okay, since you haven't been denied you just need to prove how much you need this surgery. Have you found a doctor who will perform the surgery? If not, you need to do that. They will help you provide the required information. It will be a lot of work. It will take a long time. It will be a fight. But it is possible and in fact many people are successful at getting insurance to pay in the end. Go to ObesityHelp.com and you will find lots of resources on the subject. People there will be able to show you sample letters they have used in appeals. You can also read success stories and get the names and recommendations about doctors in your area. It really is a great resource. I had regular gastric bypass 2 1/2 years ago and was lucky that my insurance covered it, but in my journey I meet a lot of people who had to fight for it. If you need more info or just some reassurance feel free to email me at [e-mail]

Answer 3

The only way they will pay for it, is if you are morbidly obese and if lack of surgery could actually be life-threatening to you. You doctor would have to diagnose you as being morbidly obese. You have to be a certain weight above the ideal weight for your gender and height to be considered medically, morbidly obese.

Your doctor would then have to refer you to a psychiatrist to ensure you don't have any mental diagnoses; if you do, then they would have to treat your mental illness and get it under control before even considering surgery.

Once a psychiatrist clears you, then your doctor can refer you to for gastric, lap-band surgery. If you want your insurance company to cover the expenses, the above process is what you would have to undergo.

If you want to pay for your own surgery, for cosmetic purposes, then you would bypass the psychiatrist part because you're paying for it, out-of-pocket. Seeing a pyschiatrist would not be a necessary requirement y the surgeon. If it's insurance paying for the costs, many surgeons would require psychiarty consult because insurance companies require those. Surgeons would not operate without it because the insurance companies would not pay them, until a psychiatrist "cleared" you.

I'm telling you all this based on my experience previous as a health professional. I am a trained health professional, I used to practice. Nowadays, I run a business instead. Perhaps, things may have changed a bit.

Answer 4

Unless you have a life threatening condition, caused by obesity, they won't cover it. I've never, EVER, seen a bariatric surgery overturn on appeal, unless it was CRITICAL to a patient's health. So, are you an insulin dependent diabetic? Vascular disease? etc... Do you know if you qualify, based on standard bariatric surgery guidelines? BMI> 30, weight-loss resistant, diet & exercise for > 6 mos, etc...

If you're going to try, start with making sure you qualify for the surgery. Be prepared to send copies of all medical recs containing info regarding weight loss. Speak with a surgeon, and get more than one opinion if possible. Send it in, and cross your fingers. People usually include info about how much $ the company would be saving if they paid for the bariatric surgery, instead of the health complications that arise from being obese. Something that confirms the current cost of your medical care can also be helpful. Its a long shot unless you have other health issues... but good luck.!!!

Answer 5

If you can win that fight, you should be able to win the fat fight without surgery. In other words, it's impossible...you won't win, don't waste your time. Especially against an HMO, for too many reasons to go into here.
You're only chance (which really isn't a chance) is if you can get a doctor to commit in writing that your current health is in dire jeopardy and the ONLY remedy is this surgery.
I have portion control issues, I just Love to eat, so I feel for you...but don't waste your energy on this fight, spend it instead on recovering from your surgery and enjoying life.
Good Luck!

Answer 6

Yes, you want to file the appeal now. If your doctor says you've tried other methods and they haven't worked, and maybe you can get a second doctor to say the same, they'll probably say, ok, take the next six months, and join (insert weight loss program here) and prove to us that the diet & excercising isn't working. You HAVE to put in that six months - then the doctor says AGAIN you need it, and the insurance company looks at the results, and that's how to get it approved.

Note, it's not my GUARANTEE that they'll approve it, that's just the process that successful approvals have gone through. Not EVERYONE appeals successfully. YOU CAN'T DROP OUT OF THE PROGRAM.

Answer 7

So if you can't maintain those goals over a long period of time now, how are you going to maintain them for the rest of your life after the surgery?? Because you have to. And it's even more work after the surgery, because you will be nutrient deprived, and will cause yourself major health problems (oh, like death) if you don't maintain the goals your doctor sets after the surgery.

Answer 8

well i'm not going to lecture you about weight. what i can tell you is that if it's not covered, then it's not covered. go to your employer (HR) and find out if they are fully-insured or self-insured. if they are fully, then all you can do is go to your doctor and see if they can appeal your case. if they are self insured then you can ask your employer if they will make an exception for you, but chances are they will say no b/c if they do for you they have to do for someone else.
there are steps/guidelines to follow before having this surgery to show that it is medically neccessary that you have this. you have to have clinical notes (dr's notes) that show you have dieted and excersided for a period of time. you have to have psychological counseling. you have to have nutritional counseling. i would advise finding out the guidelines and following them before you even try to appeal so you have a stronger case.

Answer 9

If it exclude,then it is not covered!

You could ask your doctor to contact the ins co and provide documentation that it is medically necessary. If it is excluded, it will probably do no good, but they certainly won't approve it if you do nothing.

Answer 10

go to obesityhelp.com and check your insurance company there

I had gastric bypass surgery in April 2005. I started out at 268, now I’m 180 and holding. These links will help you in many ways to make a decision if this is for you or not. I vote yes, because it made such a difference in my life. I was taking 8 pills a day, and after my surgery, I lost my diabetes. The way they do the surgery, takes your diabetes away. I no longer have to take glucophage, and I no longer have high Cholesterol or high blood pressure. I’m down to 2 pills a day. I went from a size 26-28 to a 16-18.
http://obesityhelp.com/member/rjpoole/
Most people struggle with paying for the surgery. Go to this site, it is a great support system for you, because it’s only people who have had gastric bypass or lap band. Every insurance program has been rated, and you’ll get tips on how to deal with your insurance company, as well as, surgery tips, food tips, and just support. This site is free! I’d have to rate it a #1 site if you want to learn about the surgery and how to deal with the insurance companies and get support from other people in the same boat as you.
This is the #1 site for gastric bypass and it’s free! Extremely helpful! http://www.obesityhelp.com/
This explains about the surgery:
http://win.niddk.nih.gov/publications/gastric.htm
I really researched my surgeon, and I made a wise choice. Always get a surgeon that has done at least 200 of these surgeries. Get someone with a lot of experience, and you will do well.
Here’s all about my surgeon…
http://obesityhelp.com/morbidobesity/bariatric+surgeon+profile+James+Pilkington+djp.html
http://www.cmch.org/profile-pilkington.html
You just can’t find a better surgeon than him! He’s probably done at least 500 of the surgeries, so far. I did so well after my surgery, I thank him every time I see him.
I made it to 175! It's been almost 2 years since my surgery. I haven't had any complications at all with my surgery! My health has been very good, and I've lost the weight nice and slow, so my body doesn't look that much out of shape. I've been faithfully taking my vitamins, and my blood work came back excellent! I still think very highly of Dr. Pilkington, and would recommend to anyone thinking of this surgery, to have Dr. Pilkington as his or her surgeon. I'm walking proof, that he is an excellent doctor. I just spoke to another patient of his who told me she had a very good experience with him, and she is in excellent health, as well. He is a very caring doctor. I live in Florida in the winter. I see alot of folks down there because of my job, and I see people from all over the USA and overseas. Since my surgery, I've talked to lots of others that have had the surgery in Florida, and some of them didn't do as well, and I tend to think it's because their doctors weren’t as competent as mine. I feel that part of how you do, is because of your general health and attitude. The other major part is how good your doctor is.
Here’s a website that tells what to look for in a surgeon;
http://www.texasbariatricspecialists.com/gastric-bypass-surgery.html
http://www.docshop.com/education/bariatrics/choose/
Gastric Bypass diet: (after surgery)
http://www.gicare.com/pated/edtgs22.htm
There is a very good web site by a guy named Basil White. He’s a govt. worker and a comedian. He walks you through everything. Very interesting. He had the surgery and did well. If you want an idea how people handle the surgery, read here!
http://www.basilwhite.com/gastric/
Here’s Basil!
http://video.google.com/videosearch?q=basil+white&hl=en

http://www.mayoclinic.com/health/gastric-bypass/HQ01465
http://www.mayoclinic.com/health/gastric-bypass-diet/WT00007
http://www.mayoclinic.com/health/gastric-bypass-surgery/AN01378
http://www.webmd.com/content/article/46/2731_1654.htm
http://www.lapband.com/lapband/aboutlapband.do
A must read if you have questions:
http://www.liteandhope.com/livechat_archive1003.html
http://www.bariatricedge.com/dtcf/pages/finding_support.htm?WT_srch=1


Check out this link, this lady put her heart and soul into it, with lots of great info:
http://www.gastricbypassfamily.com/index.htm
Vitamins I take… you have to be very faithful about taking them after surgery, because you can become very sick if you don’t. There were recommended by my surgeon and nutritionist.
http://www.walgreens.com/store/product.jsp?CATID=301120&navAction=jump&navCount=0&id=prod403359
http://www.webmd.com/hw/weight_control/hw252819.asp
Some other helpful links…
http://dir.yahoo.com/Health/Diseases_and_Conditions/Obesity/Gastric_Bypass_Surgery/
http://www.stapleclub.com/general_info.htm
http://www.locateadoc.com/articles.cfm/1454/1337
http://www.dhmc.org/webpage.cfm?site_id=2&org_id=28&morg_id=0&sec_id=0&gsec_id=35507&item_id=35508
http://www.connectionwls.com/
http://www.mygastricbypass.com/
http://www.gwdocs.com/health/eHA-eHA_Content_C-Generic_Content_Page_Template_1131123706877.html
Risks of Gastric Bypass Surgery
Gastric bypass surgery is considered the safest and most effective type of bariatric surgery. But as with any major surgery, the procedure does carry some risks.
http://www.dhmc.org/webpage.cfm?site_id=2&org_id=28&morg_id=0&sec_id=0&gsec_id=35507&item_id=35508
http://www.dhmc.org/webpage.cfm?site_id=2&org_id=28&morg_id=0&sec_id=0&gsec_id=35507&item_id=35514
Good luck with your surgery and new life!