Wind out of my sail

Hello everyone, today the wind came out of my sail. I finally got up the nerve to go for a consult for the LapBand after 3 of my Doctors reccommended it. I was so excited and wanted to have it done tomorrow, only to find out that I pay $1200 a month for insurance that does not cover it. I have been reading posts on here some positive however many more are negative about getting it covered. What do I do, I need to have this done I cannot breathe, I am diabetic, high BP, sleep apnea and can hardly walk to my car in the morning because of my knees and hips. I know all of you have heard this before, I am new to OH and have no idea where to look for help. Any and all guidance is greatly appreciated. I have read where several of you have paid for the procedure yourself, what is the average price? I don't have the funds to do the self pay, we are still paying for my husbands stem cell replacement. I look forward to hearing from you. LouAnn Jacksonville, FL

LouAnn, read or reread your policy very carefully. A lot of times WLS is not covered unless medically neccessary, so at first glance by you or a customer service agent, it looks like it's not covered, but it is. Check to see if it is covered if your pcp states that you have to have the surgery, and then also check to see if there is an appeal process. Do not give up at the beginning, all too often insurance companies make it hard to get approved, but not impossible. Fight, fight, fight.

Good luck,

steve

LouAnn- Many insurance policies have WLS exclusions --even when medically necessary.  That is just the reality of insurance today.  I have heard of people getting WLS covered through Voc Rehab when obesity is interferring with their ability to get or keep employment.  So you might want to check into Voc Rehab.  Now the thing about Voc Rehab is that they are in the business of helping people work.  That is their focus they are not a healthcare provider, so any inquiries you make of them needs to be framed around work.  Also and this may be out there .. the VA does have a program called the MOVE program that provides the RNY.  I do not know if it covers the band.  So if you can access care through the VA that might be something to check into.  My only other suggestion would be to get a job with a company that you know has insurance that covers WLS.  Corporate Starbucks provides insurance for part-time employees that covers WLS and Home Depot  I believe covers WLS for full time employees. Red

Hi LouAnn,

Triple check and see if it is covered in or out of network. It might not be covered with your choice of surgeon but covered elsewhere (like in-network.)

It costs the average pt with a BMI of 40+ $18k *more* per year that a normally weighted individual. When you look at it purely from an economic standpoint, it makes a self pay option more tolerable if you can swing it.

HTH.

Dr Cywes and Dr Baptista - are in Jacksonville.  I just checked their price sheet that I received at my consult 08/2007 --- it said subject to change. Surgery Center fee for Lap Band = 8,800.00 (Hospital fee was 10,650) Surgeon Fee = 5,000.00 Anesthesia = 250.00 for 1 hour Adjustments as needed $150-$350 $200 program fee includes history and physical by surgeon and 2 pre op visits with surgeon. Your insurance may cover some stuff... Psych Eval, Lab tests, nutritionist. Give them a call and find out current pricing to see what is available.  They are excellent surgeons and they have a monthly support group meeting.  Their website is www.obesityresolved.com if you want to check for seminar dates. Dana Zamot is the program coordinator - 904-399-4004 Good Luck! Kim

Hi there, LouAnn.   Posts like yours just REALLY upset me....not thru any fault of yours but because of these dang insurance companies.  They'll pay for all the comorbidities but they won't pay to fix the problem. I'm a patient of Dr. Cywes (that Kim talked about) and I'm a support group leader, but not at his office.  I have my own support group outside of his practice. The post about Vocational Rehab is correct.  I have met 3 girls thru our support group who went thru VR and the procedure was entirely paid for.  Dr. C has been approved to do VR work and one of our group members got him on the list.  All you have to do is tell them you can't do your job because of your weight. $1200 a month for insurance is outrageous.  And then still having bills for your husband while paying that kind of premium is even more ridiculous.  The insurance sure must not be paying much of anything. And the posts about check and double check your policy are also correct.  Does your policy have a total exclusion or will they cover RNY and not the band?  If you choose someone IN network wil they pay?  My guess is there's a total exclusion.  That leads me to believe you're working for someone who administers the policy issued by a particular company.  Let me explain:  My insurance is thru the city of Jacksonville but its Aetna insurance.  The City decides what's covered and what isn't and Aetna tells them how much the policy will cost for that kind of coverage. Now, get this....I was banded in November, 2005.  In December, 2007 I had to have my port removed because of an infection.  I was scheduled for surgery the end of January to have a new port put back in on the other side of my body only to find out that my insurance no longer covered bariatric surgery.  I filed an appeal and got approval and now have a new band.  But I didn't get it til the first part of March.  Thank goodness I only gained 8 lbs thru that time.   So, insurance changes all the time.  Hang in there.  Just because wls is not covered by your policy now, doesn't mean it won't be in the future. And, if nothing else, contact the people at obesitylaw.com.  The lead attorney is a wls patient and his entire practice is dedicated to helping wls patients fight the insurance company.  Someone else I met thru my group hired them and the attorney didn't even charge her the customary $300 fee (yeah, that's what he charges to go to bat for you.  It can grow from there but that's here it starts....or used to).  He was so ticked at the crap the insurance company was trying to feed him, he did the work for her gratus.....and he had to file THREE appeals. If I can answer any quesitons for you (or try) or help in any way, please don't hesitate to get in touch with me.  I'd be happy to assist in any way I can.  And if you'd like to start attending support group meetings, we'd love to have you.  I started the support group prior to having surgery because I feel strongly about getting support before as well as after. La Wanda