Where do I start?

I went to my family doc and told her I am interested in Lap surgery. My husband is self employeed and I only work per-diem right now so that I can be home with our 8 month old son, so we are covered by Maine Care right now. The doc told me that they would not cover the procedure because I do not have High blood pressure, diabetes or High Cholest. I have a very high BMI and I do not loose weight well at all. I am getting very depressed and I was pretty much told there was no way that Maine Care would cover my surgery. Do you have to go through your PCP and have a referral? If anyone can help I would REALLY appreciate it. Reesebaby1

Hi Teresa, Don't give up hope. Yes, you do need a referral from your PCP. And MaineCare does require at least one comorbidity (Health Issue), but that's a wide range. There are other Health Issues considered besides HBP, Diabetes or High Cholesterol, those are just the more common & frequent ones. Talk to your PCP again or call the office and tell him that you would like to be referred to a Bariatric Surgeon or Program and would like to discuss your options with him. Most PCP's will at least refer you and leave it in the hands of the Bariatric Surgeon to determine if your a canidate. The Bariatric Programs work constantly with MaineCare and other insurances, so they are up-to-date on the insurance requirements and can better tell you if you will qualify. I do know that MaineCare and alot of other insurance companies will approve a Gastric Bypass surgery quicker than a LapBand Surgery, but that is changing and is becoming a more acceptable surgery option. It doesn't mean that it's not an option. Also if the Bariatric Surgeon does feel that you are a good canidate and you go through the process and are denied by your insurance, most offices will appeal on your behalf. Sometimes the denial is just because of the way something is written....you know...red tape stuff. Keep the faith! If you truly feel that this is an option you would really like to pursue, then don't give up quite yet. Be sure to exhaust your options before turning to another program. Blessings, Yvonne

I was covered by Maine Care only when I had my gastric bypass and Maine Care paid for everything 100%. I would call Maine Care and have them send you the criteria in writing. I know that things are changing with the rulings. I had my surgery this past March. Good luck