Where do i stand with insurance

[mackten 0]

Sorry I haven't introduced myself yet, I promise I will get to that Its late and this has been driving me crazy so i decided to join instead of lurking and see if you had any opinions on where you think I stand.

I did a little digging through the wealth of information my wifes employer has given us, to find out if I might be able to move forward with this process. I am no where in a position to self pay that this time

Weight Management

What Is Covered?

Any expenses, whether surgical, non-surgical, or therapeutic (including prescription drugs) that

are related to weight management or the treatment of obesity will not be covered under the plan

regardless of the existence of any co-morbid conditions or psychological condition, unless the

patient is morbidly obese as described below.

There is a plan maximum of $35,000 in a lifetime for all services relating to weight management.

Surgery for the purpose of weight reduction is only covered when there is an underlying medical

condition present, the patient has been diagnosed as morbidly obese and the proper hospital

verification has been obtained.

All expenses related to the treatment of morbid obesity that are otherwise payable under the plan

will be considered allowable expenses (e.g. surgery, hospitalization, anesthesia, office visits for a

physician, lab testing, psychotherapy, etc. Services will be payable as described in each

respective section). For purposes of determining these benefits, the plan will base the

determination of morbid obesity on the patient's Body Mass Index (BMI) or overweight status. A

BMI greater than 40, or more than 80 pounds overweight for a female or more than 100 pounds

overweight for a male will be considered indicative of morbid obesity. A BMI greater than 35 but

less than 40 will also be considered indicative of morbid obesity where the patient has one or

more of the following co-morbid conditions; severe sleep apnea, Pickwickian syndrome,

Congestive heart failure, cardiomyopathy, Insulin dependent diabetes or severe musculoskeletal

dysfunction, that are either life threatening or which significantly impair a major life function (e.g.

mobility, ability to work, ability to self care). Additionally, the plan will review patient history for

optimal candidacy for any proposed surgical treatment according to current, generally accepted

medical practices. For example, this review will consider whether the patient has been unable to

lose weight through non-surgical, conventional measures and whether the individual’s ability to

manage the surgical intervention and required post operative care has been assessed through a

psychological evaluation. Unsuccessful weight loss attempts and lifestyle changes should be

documented by medical office progress notes.

What Is Not Covered?

Any expenses, whether surgical, non-surgical, or therapeutic (including prescription drugs) that

are related to weight management or the treatment of obesity, regardless of the existence of any

co-morbid conditions or psychological condition, unless the patient is morbidly obese. Other

limitations include:

1. Appendectomies and cholecystectomies in conjunction with surgical treatment of morbid

obesity will be considered incidental and not covered unless the individual has an existing

condition that requires the additional surgical treatment

2. Subsequent panniculectomy [surgery to remove loose skin] resulting from weight loss will

be covered only if it is medically necessary as a result a documented history of treatment

by a physician for related illnesses for a minimum of six months where the treated

condition is no longer controlled through any other means.

From what I am taking from this, to start off I need to have 2 criteria. A. Morbidly Obese (check) and B. have co-morbidities (not that I know of) Other than my depression keeping me at home and unable to work, and my back pain. I cannot think of any other issues I have.

Please help me figure out this mess

Thank you

[former_vbg 198]

Well, a couple of things as I read your post.

First, I would call your insurance company and ask them point blank. Be sure to document date/time of call/ who you talked to, etc. Start a file and be diligent about keeping it up.

Second, as I read what you listed- if you have more than a BMI of 40, you don't have to have any co-morbidities- BUT, I do see that they do require documented proof through medical records that you have tried other ways to loose weight. This is not uncommon and why you typically see most people have to go through the 6 mth supervised diet.

I think you should be ok if you have a BMI > 40. Just call your ins. company and ask them to clarify their policy on this coverage.

I hope this helps.

Sorry I haven't introduced myself yet, I promise I will get to that Its late and this has been driving me crazy so i decided to join instead of lurking and see if you had any opinions on where you think I stand.

I did a little digging through the wealth of information my wifes employer has given us, to find out if I might be able to move forward with this process. I am no where in a position to self pay that this time

From what I am taking from this, to start off I need to have 2 criteria. A. Morbidly Obese (check) and B. have co-morbidities (not that I know of) Other than my depression keeping me at home and unable to work, and my back pain. I cannot think of any other issues I have.

Please help me figure out this mess

Thank you

[mackten 0]

Well, a couple of things as I read your post.

First, I would call your insurance company and ask them point blank. Be sure to document date/time of call/ who you talked to, etc. Start a file and be diligent about keeping it up.

Second, as I read what you listed- if you have more than a BMI of 40, you don't have to have any co-morbidities- BUT, I do see that they do require documented proof through medical records that you have tried other ways to loose weight. This is not uncommon and why you typically see most people have to go through the 6 mth supervised diet.

I think you should be ok if you have a BMI > 40. Just call your ins. company and ask them to clarify their policy on this coverage.

I hope this helps.

Thank you very much for your reply!

I weighed and measured myself for the first time in years and I look to be sitting at 5'11 and 321 lbs, so a BMI of around 44.8 (higher than I thought)

I will definitely, get a hold of my insurance company as soon as possible and report back.

[mctaverne 1]

Just to let you know, my insurance company wanted me to be able to show that the "tried weight loss before and failed," as well. However, since I had never done Jenny Craig, Weight Watchers or anything like that, I had to show that my primary care physician, and I had talked about weight loss off and on for the past 5 years. What made it even worse was the fact that my PCP just recently archived all of her records due to the electronic records, and she did not include the past 5 years worth of charts that would have shown that we talked about it.

I was able to convince them through testimony from co-workers of mine that I had been working on my weight, and it had fluctuated greatly over the past 5 years. I don't want to discourage you, but I also don't want you getting your hopes up, like I did, and think the 6 month physician weight loss program will be the end.

[PlannerGirl 3]

For documenting your attempts at weight loss, I may be able to help. When I applied for my insurance, I sent in a lot of backup information, most of which I have turned into templates that can be used by otheres. if you're interested, pm me and I'll forward that to you.

When I applied for my insurance I was required to have 2 years of doc documentation of weight. I did not have it. That is why I sent a lot of additional information. I was approved on the first try and I am sitting here 8.5 months later and approximately 130 pounds lighter. Do whatever you need to do to ge this done......it is a life changer. Good luck!