Question:
Anyone been approved thru PacifiCare (hills) with a comorbidity of breast cancer?

My BMI is 36 with a previous breast cancer diagnosis 3 yrs ago. Some unexplained respitory problems, joint pain and swelling in the legs. I am just starting my journey for adjust gastric banding and have a phyc eval sched in May. What kind of fight am I in for with my insurance?    — Kelley W. (posted on March 23, 2003)

March 23, 2003
your first step is to get a copy of your insurance policy and read it carefully. If it is not clear, then check directly with the insurance company to find out if they cover WLS and under what circumstances, or check with your employer's human resources department.
   — Kasey

March 23, 2003
First, lose the attitude! Why are you looking for a fight with your insurance company? Like the other poster said, see what the policy says. If you meet criteria (and they cover this procedure) you shouldn't have any problem. If you don't meet criteria, or they don't cover this procedure you will need to explain why you need this done. Expect to be denied, then appeal. If you are considering breast cancer a co-morbid, you need to be prepared to explain how the cancer is related to being overweight and site specific medical information to back up your claim. Insurance companies deal with facts, not emotions. Unexplained respiratory problems may not be good enough. Joint pain may work if you can specifically say how it limits your mobility and ability to function on a daily basis. I would be finding out whether the procedure will be covered before I get too far into the process. Good luck!
   — koogy

March 24, 2003
Kelley, there is an insurance database at spotlighthealth.com just for people researching the LapBand. There is also a wonderful support group for Band patients, and you can ask any question you like there with a minimum of snide commentary. It's a boon for anyone researching AGB.
   — Jeanie

March 27, 2003
Hi Kelley, I just wanted to butt in here to this discussion even though it's a few days old. I work for PacifiCare in California and recently had my RNY. PacifiCare does not cover the lap band procedure. I suppose it's possible to get it covered with a fight, but that would mean taking it to the DMHC and from what I read on their website, they were upholding the decisions of the health plans... the RNY is considered the gold standard and so that is what is covered. Hope this helps as you figure out what you are going to do.
   — Janet S.

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