Preemptively writing a plea to the insurance company.

[Julianne 0]

Well, my PCP referred me to a surgeon yesterday and hopefully next week I'll get an appt for a consultation.

I am between 35-40 for my BMI (probably a 37 today) with 2 comorbidities. I think the ins co might require me to do the supervised diet. :wink2:

I'm wondering, what if I preemptively write a heartfelt letter to the ins co chronicling my struggle with weight over the last 20 years? I could include all of the diets I've tried and how it's painful to exercise much right now due to my ankles and lower back hurting.

I mean, I know it couldn't hurt to write a letter... but would it help?? I'm tired of the sleep apnea, the metformin, the unexplained headaches.... I just want to move forward. You know??

Any thoughts would be appreciated!! :crying:

[dfav3412 116]

In the package I got from the seminar I attended, I had to fill out the questions on the form I was given. There was a place to write all the diets I had been on with dates and how much lost etc. I'd wait until you see your surgery team, they will instruct you as to what you will need to do.

[Julianne 0]

Thanks for responding. :wink2:

I can guesstimate the dates of these things, but I never imagined I'd have to write all of this down. I mean, they realize this right??

[Gone23456 0]

Before submitting to insurance, my surgeon required a "self letter" written to the insurance company. He said they had better luck with approvals when the packet was sent with a letter because it makes you a person and not just a number. Plus, it makes you step back and evaluate why you are having surgery... Not that we all hadn't already done that!

For me, the "self letter" was the hardest part of my journey. I didn't enjoy laying out my failures for some random person to read...

[Julianne 0]

For me, the "self letter" was the hardest part of my journey. I didn't enjoy laying out my failures for some random person to read...

Hey, if it covers 50% of my costs, I'll make a video and pantomime it out for them! :wink2:

In all seriousness, I can definitely see how that can be hard. I guess we'll see if my surgeon is going to require it. If not, I'm going to ask to do it.

[adagray 1]

If you meet all of their requirements and have documentation for it all, I would not include the letter. My surgeon's insurance people said it can just complicate matters to add more information than they need. In my case, I did not meet my insurance company's rqmts, though, so I did include a letter. But, it didn't help. They denied me anyway. I appealed, they denied again, I did a second appeal, and they finally approved.

[dfav3412 116]

Julian, your response made me laught.

Thanks.

[TSurran 0]

I think you have to write the letter anyway. My insurance company REQUIRED that information. I was going to suggest, start going to a dietician now, see your doctor on the days you see your dietician - usually there is NO copay for the dietician (not with Blue cross blue shield) But I was denied three times. The insurance company wouldnt tell me why, well not specifically - anyway two of my dietician months did not count. I now how to go until april first. my dietician is not real knowledgeable in this field and has not had any lap band paitents (we live in a very very small town) but you have to go regardless, well I did, and the insurance company looks for any reason to say NO to our surgery.

Currently, obesity law has my case and between finally completing the dietician requirments and have the legal team on my side - I am looking for a 'YES" hopefully next month.

Good luck, I know it was a long haul with all of the tests, the sleep apnea, the xrays, the bariatric swallow etc - it was certainly time consuming.

Well, my PCP referred me to a surgeon yesterday and hopefully next week I'll get an appt for a consultation.

I am between 35-40 for my BMI (probably a 37 today) with 2 comorbidities. I think the ins co might require me to do the supervised diet. :thumbup:

I'm wondering, what if I preemptively write a heartfelt letter to the ins co chronicling my struggle with weight over the last 20 years? I could include all of the diets I've tried and how it's painful to exercise much right now due to my ankles and lower back hurting.

I mean, I know it couldn't hurt to write a letter... but would it help?? I'm tired of the sleep apnea, the metformin, the unexplained headaches.... I just want to move forward. You know?? :thumbup:

Any thoughts would be appreciated!! :ohmy:

[BetsyB 9]

I was really nervous before the ball really got rolling, too--and I was very pleasantly surprised with the ease with which I was approved. Yes, it took time--but it really just boiled down to meeting insurance requirements. No groveling was required :thumbup:

What requirements does your insurance contract spell out? Many require a BMI of 40, or 35 with 2 comorbidities. It sounds as though you meet the criteria. In that case, you have nothing to be concerned about.

Chances are, your surgeon will require that you complete paperwork detailing your diet history. His or her assessment will include assessment of comorbidities---and you will see myriad other specialists for further examination of these (a cardiologist, a pulmonologist, a psychologist, and possibly sleep specialist).

Your surgeon's office will know exactly what to do to get you approved. Furthermore, I really don't think that insurers are eager to deny claims--bariatric surgery saves them bazillions of dollars in the long run, and most people really do get approved; you simply must meet the criteria in your specific insurance contract.

As for the supervised diet, when you are just starting the process, it seems like a terribly long time to wait. But I have to say that the time is VERY valuable. It gives you time to research, to get your head in the right place, and to get your body as well-prepared as possible for the surgery. It's been my observation that those who take the time to really get ready seem to do better in the immediate post-op period. That's not to say that others don't do well--there just seems to be a benefit, IMO, in terms of mental preparation when there is a sort of enforced "waiting period."

Good luck! I will look forward to hearing about your progress. It's really very exciting--and worth any wait you have to endure.

ETA: In regard to your question about remembering all the details of past weight loss attempts, yes; they DO know that we can't possibly remember all attempts and dates. What they want to do is establish a pattern of repeated loss (or attempted loss) and/or regain.

In my case, this information was used by my doctor's office to complete the claim; it was not submitted to insurance in and of itself. (The information was used, but the surgeon and/or his insurance specialist made the determination that I met that criterion; the insurance company was then informed of his assessment. If that makes sense...)

Anyway, my point is that you don't have to agonize over minutae. You have comorbidities that are apt to cost the insurer $$ over time--and the surgery will eradicate them. The cost-benefit analysis leans heavily in favor of approval for banding in cases like this. Having the surgery will save them money, and that's what they're all about.

Edited March 14, 2010 by BetsyB

[kagead 0]

I think you have to write the letter anyway. My insurance company REQUIRED that information. I was going to suggest, start going to a dietician now, see your doctor on the days you see your dietician - usually there is NO copay for the dietician (not with Blue cross blue shield) But I was denied three times. The insurance company wouldnt tell me why, well not specifically - anyway two of my dietician months did not count. I now how to go until april first. my dietician is not real knowledgeable in this field and has not had any LAP-BAND® paitents (we live in a very very small town) but you have to go regardless, well I did, and the insurance company looks for any reason to say NO to our surgery.

Currently, obesity law has my case and between finally completing the dietician requirments and have the legal team on my side - I am looking for a 'YES" hopefully next month.

Good luck, I know it was a long haul with all of the tests, the sleep apnea, the xrays, the bariatric swallow etc - it was certainly time consuming.

Just wanted to clarify one thing with the above, BCBS coverage of nutritionist visits and classes varies by policy, even in the same state.

I have a PPO with BCBS in IL, and I had no coverage whatsoever for my nutritionist and for my nutrition classes ($70 completely out of pocket for each visit with her.) Another BCBS customer in one of my classes had 100% coverage for anything related to the nutritionist.

kagead

[Julianne 0]

I have Blue Care Network - Michigan, HMO. My dietician visits are covered with a referral from my PCP.

I was thinking about writing a plea because I don't want to bother with the 6 month thing -- I just want to get the show on the road! I think I'll have to anyway, though.

Dfav - I'm glad I made you laugh. :smile2:

I do have at least 2 co-morbidities. sleep apnea, PCOS (which, at my age, is a comorbidity and I have 6 years of infertility dx documented), and I'm insulin resistant with a recent high end of normal A1C reading.

Looks, though, like the Dr I've been referred to (I have my seminar on April 1 and first appt on April 15) only does RNY and (my choice) the Sleeve. So I'm off to find a new forum unfortunately.

Any suggestions? :thumbup:

Thank you all for your thoughtful responses. And I think the 6 months will fly by. :w00t:

:thumbup:

[Julianne 0]

Looks like I got hyperlinked to a Sleeve board! :smile2: How fancy! Thank you, board creators!

:thumbup:

[BetsyB 9]

Does your insurance require a referral from your PCP? I ask, because if you're not sure which surgery to have, it's good to see a doctor who performs all of them, and can guide you to the best one for your particular needs.

You might also find that insurance does not cover the sleeve, even if the surgeon you were referred to only does it and RNY; if so, RNY by default --if that's not the choice you want to make--is not a decision that should be made simply because of one referral.

(I hope that made sense!)

Good luck to you, no matter what route you take!

[Julianne 0]

Yes, my PCP wrote the referral for this surgeon in particular. You definitely make sense!

I am going to the seminar on April 1. The person who handles the insurance stuff at the dr's office deals with my insurance company all the time and said that they approve both surgeries. She also said that they are the fastest and most pleasant company to deal with.

Anyway, thank you!!! :thumbup:

I appreciate your help!!

Does your insurance require a referral from your PCP? I ask, because if you're not sure which surgery to have, it's good to see a doctor who performs all of them, and can guide you to the best one for your particular needs.

You might also find that insurance does not cover the sleeve, even if the surgeon you were referred to only does it and RNY; if so, RNY by default --if that's not the choice you want to make--is not a decision that should be made simply because of one referral.

(I hope that made sense!)

Good luck to you, no matter what route you take!

[BetsyB 9]

If my insurance had covered the sleeve, I would have been hard-pressed to make the decision--it is very appealing in many ways. I'm very happy with the band, but if I should ever require revision, that's the route I'd take.

Good luck! I hope you get lots of good info at the seminar on the 1st, and move along toward your goal quickly!