Problem With Pcp And Insurance Approval For Lap Band

[jMat 2]

This is my first post. I was hoping for a little better one but I have a "issue" that I could use some advice on.

My primary care doctor (if you can really call her that) is seemingly against any WLS. I mentioned the band back in May during my annual checkup and she seemed off put by it.

Flash forward to today, I'm trying to shoot for a Dec approval and a January banding. So far I've passed all my prereq's with flying colors (pulmonologist, blood clot test, nutritionist, and tomorrow is my psych eval). The problem is, my insurance company requires a letter of necessity. Not a approval for surgery, but essentially my PCP to confirm that I'm overweight and do in fact need the surgery.

This is the problem. They claimed that back in May when I went for blood work my liver enzymes came back a little high and I never got it rechecked (never recieved a call). After explaining to them that I do not need medical clearance, rather just them confirming I've been overweight, I agreed to just get the test done again.

Today I got the call that they are still elevated and they would not sign the form unless I now go for a hepatitis screen and a lover ultrasound. Again I've explained that I'm not looking for clearance but essentially them to confirm I could benefit. They would hear none of it. My surgical coordinator had even called them (before I even went for test) to explain since they recieved no response. She wound up calling me that night telling me how nasty the girls at the office were to even her.

Im kind of angry and also a little frustrated. I really feel like they are stonewalling me, especially since they know I'm pushing for a 2011 approval due to insurance reasons. I'm not saying I don't want to get the tests done (heck better safe than sorry), but for the sake of approval I feel that they should sign a darn letter saying I've been fat!

Am I overreacting to this, or given that I have a PPO should look into going to a PCP that is a bit more WLS friendly for this letter? I have no problem going for a checkup / eval with a new one, especially if they understand the request or would that completely screw with my approval?

According to the WL center I am eligible due to BMI with no comorbities. From my last nutritionist visit which I was at my highest weight of 348, I'm now down to 334 as per the pulmonologist yesterday (about 1 week apart). I'm really trying to do this right, I'm just not sure what to do.

Sorry about the long drawn out post, as I admit I'm venting a bit. Thanks in advance for any advice.

J

[Dulci 108]

Suggest that the surgical coordinator request a copy of your PCP's treatment notes for the past three years. Your PCP's notes should document your weight and blood pressure at each visit as well as noting any recommendations by your PCP that you lose weight. Perhaps that may be enough to document medical necessity for insurance approval purposes.

[cheryl2586 3,053]

Your pcp does have to clear you for surgery not the surgeon. She must write a letter of medical necessity but she must also clear you for surgery and part of that is having blood test that are normal. If your liver enzymes are elevated then the surgeon will not do the surgery. Anyone having surgery has to be cleared for surgery by their pcp.

[SHC 6]

Sorry to hear your having some problems..but to my understanding, if you have a PPO you can switch "PCP" at any given time for what ever reason, double check your policy to be sure, I know my policy allow me too! Remember your health comes 1st and I'm sure there's plenty of dr's out there that is willing to give you a letter as well as making sure your labs are within normal range..Good luck!

[NYC Girl 14]

Sorry to be negative on this, but doing surgery on a patient with Hepatitis is dangerous for both the surgeon and the patient. Your PCP is right to request the Hep test and the ultrasound before giving you the letter of necessity. Otherwise s/he might be accused of malpractice.

If your WLS is willing to go ahead before being assured there is no hepatitis present, I would look for another surgeon!

Get the tests!

Lisa in NYC

[MelindaH 3]

I have to agree with the other posters that requesting your records is critical even if you have to pay for them. If the request goes office to office you shouldn't have to pay for them. I would get the recommended tests that your pcp is requiring and see how that goes. Your pcp should have been talking weight loss strategies all along and hopefully that is documented. She should have given you WLS as an option.

As said above, you have to have PCP clearance for surgery. I do not know of any way around it regardless of insurance coverage. It seems to be a universal requirement. And Lisa is right, no surgeon worth anything would do surgery on someone with elevated liver enzymes without evidence of hepatitis status. The hospital and staff really take offense to that.

Hon, take a deep breath and relax. It all works out in the end. I can personally attest to that as I had surgery on Friday.

I sincerely wish you all the best.

Melinda

[jMat 2]

Thank you all for the replies. I think I didn't explain the issue clearly. I want to go for the liver tests, no question about it. However for the first insurance approval, all they want is a letter of necessity not clearance. Heck, I wouldn't even consider clearance with not knowing, so I wouldn't expect them. I just need them to sign a letter saying I'm heavy and have been advised to lose weight in past.