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Archive for the ‘Insurance Industry Surgery Standards’ Category

Yes, Blue Cross Blue Shield Covers Lap Bands Surgery II

Posted by Lori on July 15, 2009

I just spoke with the wonderfully informative Eloise Bray at Centennial Center For The Treatment of Obesity in Nashville, Tennessee and they have a current list of insurance companies that cover bariatric surgery available on their site.  Three pages worth. Scroll down to the bottom of the page, and they offer a PDF on each of the companies they have listed. In the next few days, I’ll do a post that links all the companies they cover for the link-a-phobics amongst my readers.

This group has a really good site with a lot of great information available. They’ve recently revamped and have been very conscientious to include a lot of the information that prospective patients are looking for. Whether you live in the Nashville area or not, I’d encourage you to spend some time looking around. They answer a tremendous number of relevant questions.

At the bottom of their home page, they have a calculator that allows you to determine your BMI. If you haven’t done so yet, that’s the first step in your journey.

Now, real life calls. I’m going to look around their site some more, but in the meantime, I’d encourage you to spend some time there as well.

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Lap Band Patients Continue to Lose Weight Over Years

Posted by Lori on May 4, 2008

I just checked in with Dr. Chris Oliver, my favorite Lap Band blogger. He’s 16 months post-banding and has lost 55% of his excess weight. He’s riding in bicycle tournaments, competing in triathalons and he looks great. If you haven’t read his Lap Band blog, by all means, check in. Being a physician, he writes with a level of detail and precision we don’t get with most Lap Band bloggers.

Anyway, he’s blogging about Dr. Jean Biagini and Dr. Lamissa Karam’s Lap Band study out of Lebanon that followed 591 patients with an average BMI of 41.95 (that’s our 5’4″ woman at 235 and our 5’11” man at 290) that had a Lap Band procedure. Fifty-one of the patients wound up having their Lap Bands removed. The researchers followed their weight loss for up to ten years. After the first year, the patients had lost, on average, 66% of their excess weight. At the end of the second year, they had lost, on average, 72% of their excess weight. At the end of four years, 75.9%. And, most delightfully, at the end of six years they had lost, on average, 82.8% of their excess weight! How exciting to learn that people continue to lose as time goes on.

If you want to check your BMI, you may do so here. For the newbies, most insurance standards require that you have a BMI of 35 with at least two co-morbidities – meaning high blood pressure, diabetes, sleep apnea or high cholesterol before they will cover it. If you have a BMI over 40, usually you don’t need the co-morbidities. I have a link to a list of the standards for several dozen insurance companies here.

Posted in Insurance Industry Surgery Standards, Lap Band Bloggers, Lap Band Studies, Weight Loss Surgery | Tagged: , , , , , , , , , , | 1 Comment »

Sending Diabetes Into Remission With Lap Band Surgery

Posted by Lori on March 17, 2008

Lots of interesting stuff in this article from Myrtle Beach Online – it even addresses the mortality rate of an experienced gastric band surgeon versus an inexperienced one (hint – make sure your surgeon has performed more than 20 procedures). Mostly, though, it’s about how effective weight loss surgery is at sending diabetes into remission, and how much safer the Lap Band procedure is as opposed to the gastric bypass procedure. Lap band procedures have a success rate of 76 percent curing diabetes II.

Four years ago, Dr. Donald Balder of Conway Medical Center’s Weight Loss Center began performing weight loss surgery to treat diabetes in patients.

A recent landmark study out of Australia provides the strongest evidence yet that weight-loss surgery can send Type II diabetes into remission.

The Journal of the American Medical Association published the results of a study in January that stated patients who underwent surgery to reduce their stomach size were five times more likely to witness a disappearance in their diabetes over the next two years than patients undergoing standard c

That’s impressive. Patients who undergo weight loss surgery are five times as likely to see a remission in their diabetes as people who use standard treatment – ie, drugs, diet and exercise.

What I didn’t know was that a lot of doctors had concerns that since the Lap Band procedure is so much less dramatic than gastric bypass that it might not work as well. However, that has proven to not be the case.

According to Balder, many doctors felt that the newer lap-band procedure, which has been done in Australia for more than a decade, wouldn’t resolve diabetes as effectively as gastric bypass surgery.

“We feel as though there’s some sort of hormonal changes that go on when we staple the stomach, which is why they didn’t think the band would cause the same changes,” he said.

“But the band has caused the same changes without the increased risk of death and all of the complications of weight loss surgery.”

And:

Gastric bypass, which has been studied extensively in the United States, has a cure rate for Type II diabetes of about 84 percent.

Susan Michaels of Loris is a local patient whose diabetes is now remission and who is off insulin.

One of these patients is Susan Michaels of Loris, who had Type II diabetes for five years and took insulin as well as two types of blood pressure medication. After finding that dieting and exercising proved unsuccessful in her attempts at weight loss, Michaels read about the link between diabetes and weight-loss surgery in the newspaper.

“I turned 50 last year and just thought after 25 years of being obese I needed to do something other than what I have done,” she said. Since her lap-band surgery at the Weight Loss Center in May, Michaels has lost 54 pounds and no longer needs insulin.

“It’s a wonderful feeling to no longer need diabetes medication. I exercise easier and eat so much less than I did before banding. I am now down to one blood pressure medication and may be off that by the end of the month,” Michaels said.

“I do not have to say I’m diabetic anymore. I feel so much better about my health and am still working on losing even more weight,” Michaels said

And the numbers are here:

Blood tests showed diabetes remission in 22 of the 29 surgery patients after two years and an average weight loss of 46 pounds, while only four of the 26 patients in the standard care-group eliminated their diabetes, losing an average of three pounds.

“This new study that comes out of Australia is very remarkable in that it has a nearly 76 percent cure rate for Type II diabetes, which is an extraordinarily high cure rate for a difficult disease,” Balder said.

And for people who are lower weight and have Class 1 diabetes, it’s even more effective. One hundred percent of those people saw their disease remission. Insurance isn’t likely to pay for that now, but hopefully, with enough people challenging that, it will change.

Weight-loss surgery can help patients with Class I diabetes, or a body mass index of 30 to 34.9, and Class II diabetes, or a body mass index of 35 to 39.9, although weight-loss surgery is currently focused on morbidly obese patients, Balder said.

“Another study in Australia done on people with Class 1 diabetes showed that folks who had lap band at that weight all lost their diabetes, but unfortunately we haven’t gotten insurance to pay for that smaller weight category here yet,” Balder said.

It has taken me a few weeks to cover this, but it did need to be covered. Diabetes is terrible disease. Both my mother and my grandfather died in their early sixties from heart disease because of it – it’s not to be taken lightly. Lorraine Kay, whose interview I will have up today, is legally blind because of her diabetes. The costs to that disease are tremendous. This research is very, very good news.

It’s a beautiful day in Los Angeles. The sky is that bright, bright blue and the sunlight is beaming off the clouds. Flowers are blooming like mad and it’s baby plant green everywhere you look. The wind is a bit brisk, so allergies are acting up everywhere. But I’m going out for a walk and it should be a lovely one. I hope you get a nice nature break as well.

Posted in Insurance Industry Surgery Standards, Lap Band, Lap Band Basics, Lap Band Studies, Lap Band Weight Loss Stories, Lap Bands And Diabetes | Tagged: , , , , , , , , , | Leave a Comment »

Yes, Blue Cross Blue Shield Covers Lap Band Surgery

Posted by Lori on March 14, 2008

I think that’s the search I’m seeing turn up more than any other. At the Centennial Center For The Treatment For Obesity, they have the criteria for lap band treatment for Blue Cross/Blue Shield in Alabama, Arkansas, Federal Employees, California, Florida, Georgia, Texas, Anthem (Kentucky, Virginia, Wisconsin, Ohio), Empire, Missouri, Maryland, Massachusetts, Michigan, Minnesota, Nebraska, New Jersey, North Carolina, New York, Pennsylvania, Independent Blue Cross Pennsylvania, South Carolina, Tennessee, State Of Tennessee Employees, Tennessee – St. Thomas and Baptist Hospital Employees, Regence (Washington), Mountain State (West Virginia), and Highmark (Pennsylvania). As well as CHA Health, United Healthcare, Aetna, Unicare, Medicare, Definity Health, Cigna, Humana, Humana Medicare Gold Choice, Healthspring PPO, Healthspring Medicare Plus, CHAMPVA – Tricare or Champus, Tricare Standard, First Health, TennCare Bluecare, TennCare Select, AmeriGroup, Tenncare Americhoice and Great West Healthcare. They add new companies as they get them so I might not have all of them listed. Scroll to the bottom of the page, and you will see a PDF link for every company they cover.

If this is one of the first websites you’ve been to and you’re trying to figure out if you qualify, the basic standard for most insurance companies is a BMI of 35 with co-morbidities (diabetes, high blood pressure, high cholesterol or sleep apnea), or a BMI of 40, and documented attempts at weight loss. And then each program will have their own little particulars. The criteria can change as well, so just take it as a guideline.

If you need to calculate your BMI, you can do so here at the bottom of the page. For instance, a guy who is 5’11” and weights 275, would have a BMI of 38 – so he would need some co-morbidities to have it covered. His ideal weight would be 165, so he could conservatively expect to lose 77 pounds. A woman who is 5’5″ and weighs 250 would have a BMI of 42 so she wouldn’t need the co-morbidities. Her ideal weight would be 138 and she could conservatively to lose 78 pounds with a lap band.

Sorry for the boring post. Just wanted to put it out there for all the link-a-phobics looking for quick answers.

Posted in Insurance Industry Surgery Standards, Lap Band Basics, Weight Loss Surgery | Tagged: , , , , , | 66 Comments »

Fantastic Attorney Page For Insurance Lap Band Denials

Posted by Lori on February 19, 2008

The Northwest Weight Loss Surgery site has a link to one of the best pages ever – Obesity Law And Advocacy Center. Attorney Walter Lindstrom is founder, and he is specializing in laws and discrimination that impact the obese. Now, if you’re reading this page, you’re not planning on being obese for long so you may wonder how this impacts you!

Well, Mr. Lindstrom has a lot of advice on what you need to do to get your insurance to cover your lap band procedure. For starters, a lot of insurance companies mandate that you establish that you were on a supervised diet program and require that you provide them with notes. He has an entire paper on the importance of doing this. His basic point is that for many of us, getting insurance approval isn’t that quick anyway. Most doctors want you to lose 10 pounds or so before surgery to make the liver smaller anyway, so Mr. Lindstrom says “do it”. It will get you a little farther down the road while you work through the insurance issues, and will make you healthier for the surgery.

There are lots of articles and FAQ page as well. There were two questions that particularly caught my eye and I think will be relevant to many of you.

I’VE BEEN DENIED OBESITY SURGERY BY MY INSURANCE COMPANY BECAUSE CLAIM IT ISN’T MEDICALLY NECESSARY. CAN YOU HELP ME?

We are fortunate to be able to help most anyone in this position and have a success rate overturning denials based on “medical necessity” or failure to meet criteria for surgery that is in excess of 90%. We can be most effective if we get the case or claim right at the time of the first denial. If you wish to inquire about us advocating for you in that type of case, click here.

Oooo la la! A success rate of over 90%! That’s what I want to hear!!!!!

And then this:

MY INSURANCE COMPANY DENIED ME BASED ON A LACK OF DOCUMENTATION OF WEIGHT LOSS EFFORTS AND I DON’T HAVE ALOT OF THAT INFORMATION….CAN YOU HELP ME?

This is one of the areas we spend a great deal of time and have had very good success. While it is very, very important for patients to go back to their various medical providers to get whatever historical records are available, the fact is many people don’t have or cannot locate such records. That should not stop anyone from seeking surgery. First, you can always postpone the surgery until you comply with your company’s requirements, whether they are 6 months, 12 months, 18 months or more. However, we also understand that many of you have “been there, done that” and don’t want to wait anymore. We work successfully on a great many of those cases despite a client not having a great deal of documentation and we would urge you to give us a chance if this is the basis for denial you confront.

This was something I was wondering about. I live on a diet. I don’t think there are that many changes I could make to my diet that would allow me to lose weight. But after reading this site, tomorrow I’m going to be figuring out ways to get on a supervised diet, just in case I wind up with insurance coverage and use it for my surgery.

And in case you need help but you’re thinking you can’t afford Mr. Lindstrom, he says this:

ISN’T HIRING AN ADVOCATE GOING TO BE VERY EXPENSIVE?

Fear of professional fees are unfortunately one of the primary reasons why many Americans, in our opinion, are denied access to health care they require. Many people cannot afford costly fees and many attorneys and other types of advocates charge fees which are greater than the costs of the treatment being denied. Obviously, in that case, it would make no sense to hire such a person or firm.

Our office has worked very hard to make high quality services affordable to anyone who needs them. We have kept our overhead extremely low and have streamlined our file handling to maximize results for our clients. We’ll discuss our various fee options with you on an individual basis, but our current structure starts under $500, depending on what you require.

While it is important that this office charge and collect a fair fee for the work that we do, we have never allowed someone’s ability to pay fees to be the final deciding factor as to whether or not we can help them. We don’t want anyone to not contact us simply based on an erroneous assumption that hiring us is too expensive. We will work hard, if necessary, to create a payment plan which meets your personal situation.

And since most of you don’t live in California:

I DON’T LIVE IN CALIFORNIA – – – CAN YOU STILL HELP ME?

The answer to this question is generally “Yes,” but circumstances will differ from case to case. First of all, you must understand that you are retaining our services as a designated authorized “representative” to assist you with your appeal; we are not acting as an “attorney” on your behalf. In those instances, it is generally not necessary for us to be admitted to the bar for your state.

If we take on the matter as attorneys (rather than as lay advocates), we do have to be admitted to practice in the jurisdiction for that case. In those instances, we associate local counsel to assist with following the local rules and to sponsor our admission to that state’s bar for purposes of that particular case. That is called being admitted pro hac vice (for purposes of that case).

There are a few things to keep in mind. If you want us to help you with your appeal, you’re not going to be obligated to file any type of lawsuit or arbitration or other type of litigated solution to the dispute. You’re also never obligated to keep us as your attorneys if you wish to file such an action; in fact, we too retain the right to not move forward with a litigated case and, in some instances, we may be unable to take on that representation because we may be witnesses to the payer’s conduct.

So. yes, he might very well be able to help you even if you live out of state.

There is a lot of great stuff to read there, so I’d encourage you to spend some time at his site. He has an entire paper on getting your insurance carrier to approve you. I’m going to read that tomorrow and report back as well.

Posted in Appealing Insurance Declines, Insurance Industry Surgery Standards | Tagged: , , , , , , | 1 Comment »