Nervous About Insurance Approval..help!

[marzee0728 0]

Hi everyone. I am just beginning this whole process. I'm from Northeastern Pa, 25 years old. I have gone to my doctor and he supports me getting the VSG done. I have BCBS of Nepa, First Priority Life. My insurance covers the surgery. They do not require a 6 month supervised diet. I just called the Wilkes-Barre Bariatric Center yesterday and registered to go to a seminar on July 19th. The woman that I spoke to said that the process usually takes about 3 months with them. I feel confident in having all of my requirements for insurance approval except the required "5 years of recorded obesity". I'm nervous because I have been going to the same doctor since 2005 but I haven't gone every single year and my weight has fluctuated throughout the years. I have ALWAYS been considered overweight OR obese by my doctor, until recently I have been "morbidly obese" with a BMI of 44. So I guess my question is, has anyone had trouble with 5 years of documented weight with their insurance? I hope this makes sense!!

[luvrkb 34]

My insurance just needed the surgeon to say in his report how long I have been struggling. Don't worry. The surgeons office knows all of the insurance 'tricks'.

[karenb4729 309]

I started my process last October but only had 4 of 5 years with a BMI of 40+ so I had to wait until January when I went to my PCP and recorded the 5th year of BMI at 40.

[Giselle3264 175]

I had a BMI of 40+ 4 out of 5 years. But the year I was down was when I received chemo for breast cancer. Even though my requirements don't state it, the surgery coordinator also sent proof of my sleep apnea and my hypertension as co-morbidities. I was approved in about a week.

G.

[Wheetsin 714]

You don't really (usually) need to have a record per year, or anything like that. Back when I was submitting for my lapband my insurance co wanted 5 years of weight history alsos howing obesity. I have them 3 office visit records, all showing an obese weight (I rarely went to the doctor then). That worked just fine for my ins. co.

Do you have something from 6/2007 or earlier with an obese weight? If so, put it in and see if you can find an alternate for the ones where your weight was not classified as obese. ALso, think of every possible place where your weight might have been recorded. It's not just PCP. ER visits? OBGYN? Acute care clinic? Etc.

[Erin6573 10]

My insurance denied me and I ended up as a self pay patient. I was with Blue Cross Blue Shield of Alabama. Their requirements were 6 months of diet documentation, along with 3 years of proof that I was morbidly obese 40+ on the BMI scale or if not morbidly obese, had a co-morbidity to go along with it. So I played their game and did the 6 months. I have moderate sleep apnea so I have the co-morbidity (or so I thought) and the surgeon submitted and I was denied...their reason: because at some point in 2010, my BMI dropped below 40 and they didn't consider my sleep apnea severe enough, it was only moderate and not severe. So my options were to make sure I was fat enough for 3 straight years or move on to self pay, which is what I did. The insurance coordinator said that she was shocked at how closely they looked at my medical records. She said most of the time they just look at the 6 months worth of diet documentation and go off the letter of necessity from the surgeon and the letter of support from your doctor and you are good to go. Unfortunately for me, there was nothing for me to appeal on because I just wasn't "fat enough" sometime in 2010 when I went to Weight Watchers for a while and lost 40 pounds. I was actually quite aggravated with the insurance coordinator at my surgeons office because through this whole process she kept telling me to not get discouraged, it would happen, they have an excellent track record getting people approved. And then when the denial came, she was like...well sorry, but there is really nothing we can appeal on. Let us know how you want to proceed. So much for "don't get discouraged, we will get this done for you" I ended up switching surgeons because my original surgeon was somewhere in the ballpark of 15,000 for the self pay and I found another Michigan surgeon doing self pay for 11,200, so I went with him. Good luck to you on your insurance approval. I'm pretty sure the person who looked at my chart was 110 pounds and eating a celery stick while she was typing my denial, never having a weight problem in her life. LOL.

[kimmy*custis 276]

If you have a good surgery clinic, they know how to word the paperwork for the insurance company. Good luck to you!