does insurance always cover you with a 40 BMI? (GEHA INSURANCE)

[nursemommypaige 0]

Okay this is what my insurance says (roughly-it wont let me copy and paste):

-has to be 18 or older

-clinical records support BMI of 40 (or 35-40 with life threating comorbidies) for a period of six months

-documentation showing that you have had failure to lower BMI (within the past 12 months) following a doctors supervised medical progrom of 6 months or greater.

-if those are met, then they will only cover it if surgery is done in a hospital that is certified as "well qualified" by the Center for Medicare and Medicaid.

Our insurance is GEHA, a federal insurance. Basically, I am taking this to mean if I am above a 40...and stay fat for six months (and do the doctors weight loss) they will not turn me down. Is that correct, or has someones insurance come back on them and not pay after meting all requirements?

[Cocoabean 430]

GEHA brochure also states that you must get precertification. The doctors will be checking that you can withstand the surgery medically.

Your surgeon may have a battery of test he wants performed to be certain of your exact health status before proceeding. So, even though you may meet the criteria stated in your plan, you still need a surgeon who agrees that the surgery will benefit you and that you are a good candidate for it.

That said, if the surgeon is willing, the hospital is well qualified (or however it was worded), and the insurance turns you down...you file an appeal and fight it. It is a procedure they cover, your doctor says you need it and that it will benefit you.

This forum has lots of information on appeals. I had to file and won. My medical group turned down my primary care doctor's referral to see the surgeon due to the 6 month supervised diet requirement. I gave them weight watchers records, journal records, and some other information from years gone by to show that another 6 months would make no difference. I won it.

Best wishes to you!