Tuesday, May 3, 2011

Denied For Lapband

I was very lucky to work for an organization that not only has a Bariatric Surgery of Excellence Program (at the time, it was only the 5th in the country), but our insurance basically pays for weight loss surgery 100%.  From the time I attended the seminar, it took me about 6 weeks to get my cute, yet plump, behind on that operating table.

I don't know how hard I would have fought if I had been denied for surgery.  I think I probably just would have said, "oh well.  I will do it on my own"...and most likely, I would have weighed MORE than the 327 pounds I started at.

It was my sister who really got me into the seminar.  We had talked about having WLS off and on for a couple of years, but only "lightly".  And then she said something about me finding a time for us to go to the seminar...and off we went.

I don't write things down very often when I am in meetings.  I tend to just listen.  But I do believe that at our meeting in San Fransisco that statistically, if you can get people into the seminars, they are more than 60% likely going to have the surgery.  Getting people there is a big deal.

So anyways, if you remember...my sister wanted the surgery but her insurance company does not cover it.  And she is still waiting. 

So I told you that Joe from Obesity Action Coalition gave me a great booklet to give my sister on how to appeal and some insurance basics.  You can find and download this for free at their website.  Here is the link.

For those of you who are self-pay or fought appeals, I applaud you.  And for those of you who are fighting or trying to hustle up some funds...don't give up.  It is totally worth it. 


  1. I have Kaiser. I also openly LOATHE going to the doctor. But after numerous tries at losing the weight "on my own" and doing so to a degree before putting all the weight and then-some back on, I went into my doctor to start asking about options.

    Because I didn't have any health issues related to my obesity (no high blood pressure, bad cholesterol or diabetes...) I was told that I didn't qualify for WLS services.

    I believe that they tell all potential people this upfront to scare off those who might eventually qualify because after hearing the news, I know I definitely didn't push harder for the surgery. I shrugged my shoulders, figured I would be obese forever and left it alone. I already hated going to the doctor enough as it was, why bother jumping through their hoops?

    I say that if you've been denied or turned down for whatever reason - keep pushing at it. Make them uncomfortable and irritated with you. Make yourself a nuisance, not by being a jackass, but constantly be there to the point that they just want to be done with you. But don't let them win right out of the gate like I did.

    I finally got my surgery because I won it as a promotion my wonderful doctor was doing through one of the local radio stations. I campaigned amongst my friends, both those day-to-day people I interact with and my contacts online. Ultimately, even though many people have said bitterly to me that it must have been nice to get my surgery for free, I paid $4750 in taxes to have it done (any prize awarded to you over $1000 is subject to income tax, and since the surgery and one year's worth of aftercare was billed on my W2 at $16,500, that's the percentage that I had to pay).

    Best damn money I ever spent in my life.

  2. Amy, you know this already, but I figured I'd post it for any newbies who might be in my situation.

    I was a lower BMI patient (37 BMI .. 230 pounds at 5'6 tall) and my insurance would not covery my surgery. So, I self-paid and went to Dr. Roberto Rumbaut in Monterrey, Mexico. I had a friend who had her surgery with him, which demystified the whole "Mexico" thing for me!

    In any event, I have probably spent about $9,500, between the flights, hotel, surgery and my co-pay (insurance does pay for fills -- my follow up is at NYU). And, to echo the previous poster... It's the best damned money I ever spent! (And my experience with Dr. Rumbaut, his staff and their gorgeous, pristine new hospital was excellent.)

  3. My company had the Cadillac of insurance policies from the time I started in summer 1998 until summer of 2009. In that 11 year span, I could have had full coverage for Lap Band or almost anything else. But with the economy, so went our coverage.

    We still have good coverage, but our company chose the bariatric surgery exclusion to save on some premiums. I don't blame the company, it is what it is. However, my life was on a death spiral and in the Fall of 2009...right after our coverage changed, I decided to have Lap Band surgery.

    It was $9900 all-in for the pre-care, surgery costs, & one full year of after care. My surgeon was fantastic and his fill doctors are spectacular. It was a ton of money but the absolute best I've ever spent. I don't care how I would have had to finance it...if I had to do it again, I would. Over 90 pounds lighter and my life is different.

    It is funny that my insurance would pay for countless costs to "fix" my feet, my back, my knees, my high blood pressure, my cholesterol... But they wouldn't pay for the one thing that fixed ALL of it. Anyway, sorry for the dissertation. :)

  4. Great post Amy. I'm playing catch up with your posts.

  5. When I was denied the first time, I felt like the wind had been taken from my sails. Luckily the receptionist at my Surgeon's office said, don't worry, they want to know you are serious, if you fight for it, they'll pay, and they did. Thank God! I know I'd be in a much different place right now, if not for my band!

  6. I self-paid and had my surgery in Tiajuana, Mexico. It was the best, best, best thing I've ever done for myself!

    I hope your sister can make it work, but have her email me if she considers the Mexico option. I paid $6,000.00 including air fare. I got a no-interest for 12-months credit card to pay for it and have paid the cost off now. amandakiska@yahoo.com

  7. I just wanted to give anyone who's been denied a little more hope. I jumped through the hoops twice and was denied twice. I was banded 8/15/10, paid for 100% by insurance. All I paid was my $150 deductible. It can be done. Don't give up!

  8. 6 weeks? WOW. The process for the program I am going through is, at the least, 4 months. Otherwise known as an eternity... by the time I went to the seminar I had already made up my mind! Now it's hoop after hoop. At least my insurance will cover it though!

  9. I too, like Catherine, headed to Mexico for my surgery. I was so impressed with my surgeon AND the hospital. Never have I been to such a new, clean and up to the minute facility! My total costs were also about $9,500 and it was the best money I ever spent. I have all my follow-up with a great bariatric surgeon here in FL.

  10. It's a very different process in Australia. If I had private health insurance my surgeon would have scheduled me in as soon as he had a spare opening - usually within 1-2 weeks!! I had to wait 12 months for my private health insurance to kick in and then I only had to pay about $3500 (instead opf the $10-12K) and each fill is only about $40 out of pocket.

    I keep telling anyone who is considering it - to make the decision today - Don't wait - I would do it all again in a heart beat!

  11. I was furious to learn that my extremely expensive, otherwise great insurance had a complete exclusion for WLS. Naturally, when we got the insurance (self-employed but a group policy), I never thought about WLS -- I just wanted a policy that covered pregnancy!

    But once I decided to do it anyway, self-pay, it took less than a month to meet the surgeon, do pre-op, etc. Not having to jump through all the hoops was actually the one positive thing about being self-pay. My doctor in Denver was $9900, with first three fills free and all additional fills $50. However, the costs of travel quickly added up for me, since I had to fly in for my (many) fills/unfills.

    Still, it was totally worth it and I would do it again -- even self-pay.

  12. My insurance does cover lap-band at 100%, for GROUP members. I am self-employed, and my husband is a contractor, so we have to purchase the INDIVIDUAL plan, which is an exact mirror image of the group plan..... except bariatric. Apparently, individual plan members have abused the coverage (??) so they removed bariatric services.

    Because I had a hiatal hernia fixed, and a fundoplication procedure done with the band, my insurance did cover THOSE items, but not the band itself. I had my surgery at one of the best hospitals in Detroit, and paid 8800.00 all told.

    Fills are $150.00, but when I told the girls there that my insurance refuses to pay, they do fills for free for me. Sometimes, all you have to do is be NICE and ask.

    Next up? $17k for the arm lift, boob lift and tummy tuck (with port move and low-profile port swap....... gonna ask if they might need to shorten my tube, since I've lost just about 200 pounds with the band, started at 375.... I bet I have 2 miles of tubing in there!)


  13. My insurance covered. I jumped through the hoops over and over. I was low BMI with co-morbidities. The money spent was the best money EVER spent! I wouldn't give back that fight for the world!

  14. Anybody ever get Kaiser to help oay or cover it entirely in Colorado?