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Denied for sleeve trying for lap band, has anyone had any success in similar situation?

Denied for sleeve trying for lap band, has anyone had any success in similar situation?

Question Below Submitted By:  

Maggie (a patient from Washington, DC, USA)

I found out last week that I was denied for the gastric surgery, not just the gastric sleeve. I went to Sibley Hospital in DC and paid $600 for their program. They told me they would do everything and submit for the sleeve operation, but I have found out that I had to constantly call (I hounded them for at least a month) to get them to submit to BCBS.

I am 100 lbs overweight, have a BMI of 38.5, have high cholesterol – especially the Trigs, and problems with my ankles. I do not have co-morbidities yet. I am disappointed and frustrated.

Has anybody else been denied by Fed BCBS DC (Washington DC area) and been able to get approved for the lap band instead?

Also has anyone else experienced the delay with Sibley Hospital?

Is there a better facility in the Maryland, DC, Virginia area to have the surgery done with? I am also considering paying out of pocket.

Any recommendations would be great.

Thanks,
Maggie

P.S. I was done with all my program work in September and they did not even try to book the operation until till mid October. I had to call each week to get this done. I then called up Fed BCBS in Washington DC to find out if they had even submitted the request for the sleeve. I also found out that they did not submit the required psych evaluation when BCBS denied me. I asked Sibley to resubmit for the lap-band, but I am guessing that when I call them on Monday that they have not done anything.

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01.

Expert Responses to the Question Above

Some thoughts...

by: Jeff

Hi Maggie,

Insurance companies can be tough to work with, especially if your situation falls in their "gray area."

Since your BMI is less than 40 and you have no existing co-morbidities, unfortunately, I don't think that you will be approved.

Regarding your options...

First, there is legislation in the works that may reduce the required BMI levels down the road. This body mass index page remains updated with the latest requirements and info.In the mean time, there are several self-pay/cost-reducing options at your disposal, including:

  1. Payment Plan Through Your Bariatric Surgeon
  2. Friends & Family
  3. Secured Medical Loans
  4. Retirement Plan Loans
  5. Permanent Life Insurance Loans
  6. Brokers, Direct Lenders and Credit Cards (Unsecured Medical Loans)
  7. Medical travel (traveling abroad for surgery)

See this weight loss surgery financing page for all of the details.

Whichever route you take, be sure to choose the procedure that is right for your lifestyle and body rather than just focusing on the procedure that is right for your pocketbook.

The following page is a good place to start for the pros, cons, risks and average outcomes of each procedure: Compare the various types of bariatric surgery here.

I hope that helps, and please come back to this page and click "click here to add your own comments" to keep us posted.

Take care,
Jeff

02.

Patient Responses to the Question Above

Thanks for your comments

by: Maggie

Thank you for your comments. I am going to gain a little weight, since the only thing really preventing me from getting the surgery is the low BMI. I am also going to resubmit for probably the bypass or the band. Seems to be a problem to qualify for the sleeve (50 + BMI) -Maggie

HEARTBROKEN

by: Anonymous

I HAD THE GASRTIC BYPASS 13 YRS AGO AND ABOUT A YEAR AND HALF AGO I GOT HURT ON MY JOB AND I HAD TO START TAKING STERIOD SHOTS. DURING THAT TIME I gained about 50lbs. I was told by a doctor that I could have a revision due to my weight gain.

So I started the weight loss program and my insurance company Aetna does approve revisions. I went through the whole program and spent out at $600 dollars. During the program the doctor and the nututionist was aware that I was at the boderline of having a 40bmi, they stated to me on every visit that I could not go under that BMI, so i didn't. My info got submitted to Aetna on 3/9/2016 and I was denied on 3/11/2015.

I called the rep at my doctor office and she stated I would receive a denial letter in the mail and I need to appeal the denial. I asked rep why did I get denied, she stated I didn't lose any weight during the six month requiement neither did I exercise, and I told the rep I couldn't loose any weight nor excerise because it would have took me under the require bmi.

So now it's like I've done everything for nothing. Could someone please help me in leading me in the right direction.

Bariatric surgery in Mexico

by: Elida Reyes

My husband and I both had gastric sleeve 6 years ago because we were denied by our health insurance here in the United States. I'm very familiar with traveling to Mexico for healthcare.

So many people are traveling to Mexico for Bariatric surgery. Obviously, the cost is completely affordable: $5,500.

Best decision!!! I dropped down 10 dress sizes.

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Patients who qualify for bariatric surgery usually:

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