Criteria for Lap band

My insurance did not cover the surgery and although I had not actively pursued an initial consult, I was prepared to take out a loan and self pay. Recently, however, I was informed that my insurance was going to start paying for the surgery as of 7/1/05. How excited I was! When I called the company, however, the case manager, before she even knew anything about me, immediatly started discouraging me from having the surgery, and said the criteria was "very, very strict". She said the insurance required me to have my primary dr. send a letter stating 2 weight loss strategies that had failed for me. Well, I've "failed" everyone of them out there, but I did not coerlate them w/my primary care dr., and besides that, I had to change prim. care drs. pretty recently due to the fact that my previous one dissolved her paractice, and left town. None of my previous records got transferred to my current md. What's a girl to do? Aggrevated but not giving up, Vickie

Make an apointment with your new doctor to discuss your previous attempts at weight loss. Start a physician supervised diet and follow up every month while visiting a surgeon and applying for approval. Discussing your history with your physician gets this stuff in your medical record. Make sure you tell your physician your plan for WLS and that you will possibly have to make a very strong case to the insurance company. Strongly consider hiring an attorney. I've been working with Walter and Kelley Lindstrom. A lot of people here gush over Gary Viscio. Both firms specialize in getting approval for these surgeries. Caryl

Thank you, Caryl. It sure is nice to have someone out there who cares enough to offer up help. I will take your suggestions to heart. I'm very serious about wanting to pursue WLS. There is such a stigma associated w/wanting to take surgical action. I was amazed at the negative tone of the case manager of my insurance co., even before she knew one thing about me. I thought once I began taking active control of my life/health that everything would just fall into place. HA! I will not give up. Thanks for the support.

The only thing I would add, is to go ahead and have your surgeon submit a request for pre-approval. That way you will (most likely) have a denial letter in hand, with exactly what you need to perfect your claim.