Where do I start? - Page 2 - ThinnerTimes - Gastric Bypass Forum, Lap Band Forum, and Vertical Sleeve Gastrectomy Forum

deputymauldin · 04-07-2009, 10:00 AM

It really depends on your insurance. Once you know what they require, I would talk to a surgeon's office. They will be able to refer you to a PCP, which is what I had to do. My doctor told me the same thing. I called the surgeon and they gave me 3 PCP's who refer to them on a regular basis.
Good Luck

watfam4 · 04-07-2009, 10:14 AM

Quote:

Originally Posted by lillylaroo

If your BMI is over 40 that usually is enough. I have acid reflux and muscle/joint pain from all this weight. That's it. The surgeon tells me my BMI is enough but we will see how easy I get approved by the insurance. I would hope that I could trust the surgeon's opinion.

Trust but verify. Some insurance companies are easier to deal with than others. My trust in my surgeons office to be able to deal with my insurance company, cost me a couple months of delays in getting approved (FWIW). BTW my starting BMI was over 60 and it still took me a year to get approval (Cigna).

lillylaroo · 04-07-2009, 10:19 AM

Quote:

Originally Posted by watfam4

BTW my starting BMI was over 60 and it still took me a year to get approval (Cigna).

Over 60!!!! It took a year! Now I'm gonna start stressing.......

watfam4 · 04-07-2009, 11:05 AM

Quote:

Originally Posted by lillylaroo

Over 60!!!! It took a year! Now I'm gonna start stressing.......

Yep. All and all, 3 appeals over something as stupid as diet documentation.

FWIW, BMI is not a very good measure of weight for me. I am pretty lean at 250 (could drop 10 or 15 if I can get this loose skin removed

) and my BMI is still almost 34. But regardless, the BMI submitted to the insurance was over 60 (like 63).

rtnowrtnow · 04-07-2009, 11:14 AM

Quote:

Originally Posted by glocks90

Hello everyone I am new, I have been thinking about the lap band ever since my brother worked for inamed, and he told me about it. I am 100 lbs over weight and have been chubby forever. I just started going to a new pcp and he doesn't agree with surgery, great. Said diet and excersize is all I need, well i have been dieting my whole life and it hasn't worked. I have Health net HMO and they cover it if I meet all the criteria. My husband says we just can't afford to pay out of pocket, I have signed up on what seems like every lap band website no reply. I don't know where to start. Do I have to shop around for a PCP that will help me? What do I do next?

If you have an HMO you need to see your primary doctor and discuss it with him. His office will help guide you to where you need to go. At first my PCP wasn't all for the surgery either, he's all into herbs and teas but as I pressed he gave and so he set it all up for me. It's your call, you let him know this is what you need him to help you with. Also call your medical group if you have one that is affiliated with your health plan. I have Health Net HMO with Hills Physicians. They paid for everything except for my co-pays at office visits. They had a few hoops to jump through, which were: 6 mo diet with nutritionist, psych test, sleep study, 5 years of tried and failed diets (some have to provide proof, I didn't). Then when I got approved I had a few more hoops to jump through for the surgeons office: lose 25 lbs, attend orientation, and a class for diet and fitness. That's my story but call and your insurance and see what your story will be. Best of luck to you.

lillylaroo · 04-07-2009, 11:51 AM

Quote:

Originally Posted by watfam4

Yep. All and all, 3 appeals over something as stupid as diet documentation.

If you don't mind me inquiring, what was the situation with the diet documentation? I've seen the diet doc forms my PCP completes and they aren't that informative.
I'm just a nervous nelly by nature so this makes me concerned that what he writes is sufficient.

poet_kelly · 04-07-2009, 12:31 PM

I just started by finding a surgeon that did WLS and making an appointment with him. Check with your insurance, though. They may require a refferal from you PCP

Kelly

glocks90 · 04-07-2009, 01:01 PM

I actually havent seen my pcp, only the PA. she said he wouldn't agree. She said to go on a 1200 calorie diet and gave me a menu but i havent followed it because I don't have a personal chef 24 7 to make me different food all day. I have been logging what I eat and my excersize on myfitnesspal.com which you gradually eat less I have lost 6 lbs. I can always print that out.

Who knows I think i can go to a seminar on thursday and see what they say to do.

watfam4 · 04-07-2009, 01:09 PM

Quote:

Originally Posted by lillylaroo

If you don't mind me inquiring, what was the situation with the diet documentation? I've seen the diet doc forms my PCP completes and they aren't that informative.
I'm just a nervous nelly by nature so this makes me concerned that what he writes is sufficient.

I had several documented diets, but nothing recent enough for Cigna. I knew this going in so I planned a 6 month with my PCP and a dietitian. Anyway, there was a lot of general nit-picking over the doctors notes and whether my diet was a full 6 months (it was). This does not happen to everyone (just lucky I guess). My theory on this is that the insurance companies become more stringent with their "weed out" criteria when they are getting close to their quotas. Just be aware of your insurance companies criteria and do your best to fall under the radar. It really does you no good to worry about it (easy to say), as eventually your insurance will have to approve a medically necessary procedure (like mine obviously was). Sometimes you just have to be patient (again, easy to say). Good Luck.

deputymauldin · 04-07-2009, 01:17 PM

Quote:

Originally Posted by glocks90

I actually havent seen my pcp, only the PA. she said he wouldn't agree. She said to go on a 1200 calorie diet and gave me a menu but i havent followed it because I don't have a personal chef 24 7 to make me different food all day. I have been logging what I eat and my excersize on myfitnesspal.com which you gradually eat less I have lost 6 lbs. I can always print that out.

Who knows I think i can go to a seminar on thursday and see what they say to do.

My 1st pcp was a man and told me I can do what he did and eat less and work out more. My 2nd PCP was 5 feet 105lbs and said I should join WW like she did. You need a PCP who is willing to support your decision.