Yay For Open Enrollment

[djssv0523 10]

I am currently on my husbands insurance which does NOT cover WLS for any reason. His open enrollment is January 1st so hes dropping me from his insurance which will give me a "changing event" to be able to enroll thru my employer which DOES cover WLS. Im going to be getting Wellmark Alliance Select. Anybody have any experience with them?

I know that I wont have a pre-existing condition clause because I wont have a gap in coverage. The Bariatric surgeon has instructed me that I will at a minimum need a 6 month supervised diet and 10% weight loss. Im currently seeing a nurse practitioner and have four months out of the way and have lost 21 pounds. My starting BMI was 39.2 and I have hypertension. Hopefully I will be set to meet with the surgeon after the first of the year and will just cross my fingers that I get approval. The wait is absolutlely killing me! I am excited yet nervous. Any advice would be greatly appreciated.

Thank you.

[MsVeDub 32]

Have you called your-soon-to-be insurance company? If they won't talk to you - maybe have a co-worker call and ask them what the requirements are for coverage. In my experience (I have different insurance), your BMI needs to be over 40 if you don't have 2 weight related ailments (hypertension is one, sleep apena, diabetes, etc). Also, some insurance won't cover the sleeve unless you are over 50 BMI (crazy, right???), but they will cover the RNY or ring.

Good luck, and welcome to the club!!

[djssv0523 10]

Haha.. I did call the insurance company. All that they would tell me is that yes the sugery is covered however they would NOT give me the requirements. Stated that they would give them to the inquiring surgeon and that I could get it from them. My BMI when I started the supervised weight loss was 43.2 do they count that or do they go by what I am currently which is 39? I take meds for hypertension, have elevated LDL which is documented in my records as having hyperlipidemia even though I don' take meds for it. Now Im just crossing my fingers that I wont have to wait for open enrollment to get on my employers insurance because that's not until July. My six months supervised diet will be complete in January. Waiting really stinks.

[MsVeDub 32]

I had the same questions with the BMI for my Dr. I actually talked to them about it yesterday. My BMI is also 43. I was afraid to lose weight because I didn't want to get denied for surgery. This is what they told me. They (the Dr office) using my starting weight as my weight to go by. So, if I fall under 40, I should still be ok. Of course, I am aftaid she's not telling me the truth, or is mistaken, so I get where you are coming from. I would continue with your plan of action. Get that jump start in - those 6 months are the hardest (I'm in that now). If for some reason you get denied, you can always appeal. Does that make any sense??

[djssv0523 10]

Thanks for your response...looks like we are in almost the same spot! You might be a tad bit ahead of me. The surgeon won't even make me an appointment for a consult until the six months are up.. plus they want to see my new insurance card which I wont get until January 1st. Poop. At least there is still hope of getting it covered. Getting a denial and having to appeal right now is my biggest fear. I cant even wrap my head around the surgery fear since it looks like Im so far away.

[djssv0523 10]

Well I am excited to announce that I had my annual fasting labs done this morning and my total cholesterol went up! My LDL (bad cholesterol) went up! and my fasting glucose went up (only 101 but still listed as high) WootWoot! I cant believe Im excited to have failed a test. Not to mention that with the increased exercise and supervised diet plan that my blood pressure has went up as well. Hopefully the insurance company will approve me before I croak.

[funkeechiggen 135]

I suggest that you track down the clinical policy bulletin (CPB) for obesity surgery for your specific insurance carrier. The CPB will state what the requirements are for WLS for the specific plan you will be covered under. I don't see why the insurance company won't provide that to you. I have Aetna and you can find their CPB's on their website. So maybe check the website for your specific carrier.

Or, if you feel comfortable asking about it, check with your HR department and see if they can get the CPB for you.

[djssv0523 10]

I already tried that. BCBS Alliance Select apparently uses "Interqual Criteria" which is detailed on "Smart Sheets". These must be a very closely guarded secret because nobody will give them to me and I cannot find them online. When I talked to the insurance company the rep said that I would have to get that information from the surgeon. Grrrrrrrrr

[MsVeDub 32]

have you thought about another surgeon? the one you are talking about sounds like a tool, IMO. You would think the office would want to help you. You are a customer/patient. Right?

[djssv0523 10]

Haha. Too funny. The surgeons office was pretty helpful. They sent me a letter detailing what was needed for the 6 month diet and exercise plan but that's about it. They won't officially see me as a patient until my insurance switches after January 1st and can't start anything with preauth until then. Its the dang insurance company that's being a tool. Its like the requirements are a huge secret.