Torn!

 Hi everyone!

I am a newbie here, but I see how helpful of a community this is so I am hoping to get some on your input on this decision.

I was hoping to be approved by Coventry Insurance of Florida for the gastric band surgery, but much to my sadness, I was denied the authorization, according to them, because "medical criteria was not met". They wanted me to show proof of a MEDICALLY SUPERVISED 12-month, low calorie-diet, exercise and behavioral-change therapy program; and of course, I am unable to show this kind of proof. First of all, if I could successfully stick to a 12-month low calorie diet and exercise program I wouldn't be seeking gastric surgery, second of all, who has documented medical supervision of a 12-month diet program? Should I go to the Dr. every month, for 12 months, just to weight in? Do I go to the psychologist every week for behavioral change therapy? This would cost my insurance company almost as much as the lap band would!

Anyway... I have been denied. I know I can always appeal it, but how long is that going to take? Would that be even worth all the time, expectation, and hassle?

I am contemplating taking out a loan and paying for the surgery on my own. It will put some financial strain on my family - acquiring yet another loan! - but can we put a price on health and quality of life?

I feel I cannot continue to (sub)live the way I have been.
What would you do if you were in my shoes? 
Thanks in advance for your time and God bless all of you!

does your insurance require this for all WLS surgeries or just the band?

I know it's sucks another year but I would go through the process and have it covered through insurance. I would not pay out of pocket because the band requires a lot of after care, fills and unfills and it's best if you can get this covered under insurance .. mine still costs me $100 with insurance ... but be successful with the lap band long term you need aftercare ..

my two cents .. good luck

I do not know why your surgeons office did not look up the requirements and tell you before you submitted everything . It is routine for ins co. to require certain things before they will pay and yes most of it comes down to being a formality but if you want them to pay you have to give them what they want. I had to do a 3mos supervised diet , several nutritional appts (also surgeon required) several physical therapy appts (also surgeon req) a psych eval (also surgeon req) and then my surgeon's office collected all my info and sent it in for me and then waited for approval (3wks) then scheduled surgery and had to go thru an EGD , bloodwork , a class @ surgeons office, EKG, Then there are preop things to do at the hospital. It is a process you have to go thru it takes awhile and your surgeons office should guide you thru it .
I think self pay should only be a last resort as a previous poster said there is alot of aftercare and follow ups and they are expensive. Your band will not work w/o fills and it will most likely take more than one to feel anything. I have gone in once a month for the last yr to check in and for fills. one fill at my surgeons office w/o ins is 275.00. Also if  you do not get your surgery thru ins they will likely not pay for anything remotely related to your band . So it could be quite the gamble to self pay.

Contact your surgeon and find out from their insurance people what will satisfy the insurance requirements. Sometimes iti is as easy as joining Weigh****chers. I would not pay cash for your band because it is not only expensive, the maintenance is expensive and if it doesn't work for you then you would be paying on a loan for nothing. It does happen.

I hope you understand that with the band you will need to follow a food plan in order to lose weight, anyway. The band won't cause you to lose weight. If you were to get started, now, you may find that the ins. company may change their requirements before you are finished, making it less time. Mine did.

The insurance companies don't necessarily want you to lose a lot of weight to meet requirements but rather to show an effort. Again, talk to your surgeons staff. All this is frustrating, but please don't go rushing out to get a loan. You might find yourself getting more healthy and if you still need wls you would be in a much better condition.

 Thanks, everyone!

My Dr.'s office did tell me what the insurance requirements were.... they are pretty good, I can't fault them.
Although this was a requirement, it was not strictly enforced by them... but now they seem to be "tightening up" with their requirements, since gastric band is becoming more and more popular, I guess.

I am aware of the maintenance expenses of the band... those would be out of pocket for me regardless of whether the insurance picked up the bill for the surgery or not, and you're all right; that is quite a bit already.

I just feel that waiting another year is just inconceivable! I feel I am so ready for this change!
Thanks for your input. I guess I have a lot of thinking to do....

I'm not sure you can appeal this requirement because many insurances call for supervised diet for 3-12 months depending.  The thing is, they don't require recorded WL, only that you were on a program.  I did mine for 6 months and didn't lose more than 3 lbs.  BUT, I will say, it was one ov the most valuable things I did in regard to my LB surgery because I learned SO much! 

My surgeon offers the supervised diet as part of the Surgery process and it's rolled into the price.  I worked once a month with the dietician and learned a TON about nutrition and how to live with the band and what to expect.  I'm sorry your requirement is 12 months, but it will be worthwhile.

If you self pay, make sure that after care is included in the price because the band need a lot of maintenence, especially in the first year or so.  Fills are expensive if they aren't covered by insurance.

I'm surprised your Surgeon didn't help you with your insurance before they submitted the paperwork.  My surgeon has an insurance specialist in their practice that worked with my insurance and told me what I needed to do. 

I'm sorry for your troubles but maybe you need to have more conversation with your Surgeon to see what exactly they cover as part of the surgery price.

Hang in there, it's worth it!

Lisa O.

Well ----  when I was ready to change my life, I was ready.

My insurance did not cover WLS at all --- and my husband's did -- but, I would have had to wait 8 months to switch to his insurance company, and then begin the qualifying process with them.

I chose to self-pay and get on the road to my 'new life'  --- but I did not have to borrow money to do it (thankfully).

If I was going to start over and self-pay for WLS, I would opt for the VSG procedure.
Much less follow-up care required and seems to have better results than Banding.

I am thrilled with my band --- but I would not self-pay for one again.

 Thank you for your testimonial!

This was most helpful to me, since you have actually gone through the same dilemma.
Please clarify: If you are thrilled with your band, why wouldn't you pay for it again?
Thanks again to all *****plied!
God bless you all and congrats on all your success!