Wareham, mass

[gabrielle2014 38]

Hey Terry - I also have BCBS RI - I've read all the requirements - and I'm trying to gain 5 pounds or so to be sure I qualify. Did you have to go for alot of tests before hand for insurance approval? I suppose it all depends on your personal health situation. I'm just new to BCBS RI - not familiar with getting this kind of thing through. I'm 5 or 6 pounds awawy from a 40 BMI - but I do suffer from Afib (heart condition) though I'm not sure about hypertension.

[terry1118 1,274]

Hey Terry - I also have BCBS RI - I've read all the requirements - and I'm trying to gain 5 pounds or so to be sure I qualify. Did you have to go for alot of tests before hand for insurance approval? I suppose it all depends on your personal health situation. I'm just new to BCBS RI - not familiar with getting this kind of thing through. I'm 5 or 6 pounds awawy from a 40 BMI - but I do suffer from Afib (heart condition) though I'm not sure about hypertension.

My bmi was 47 and I was on meds for high cholesterol. I have mild scoliosis and the extra weight was causing back pain. I was borderline hypertensive and pre-diabetic. One of the requirements to qualify for WLS with my healthplan was a supervised and documented weight loss failure. I did Optifast at Miriam Hospital about 4 years ago. I lost 80 pounds but gained it all back in 18 months.

The pre op tests are required for surgery and were completely covered by my insurance. I had lots of lab work, an EKG, chest xray, pulmonary tests, a cardiac stress test (2 two hour visits), 2 psych appointments, 2 nutritionist appointments, medical clearance, 3 workshops, and a nurse education class. The stress test was required because I'm over 50. I don't think you need one if you're under 50. They were great about scheduling appointments to fit into my work schedule.

[charmed096213 10]

Yes I had surgery on 8/8/13. I had lap to rny revision. Love it!!!

[gabrielle2014 38]

Hey thanks Terry. I just called BCBS RI and they spelled out in a bit more detail what was required. I'm quite worried about approval. But it helps to know going into it what I'm looking at.

[gabrielle2014 38]

Terry - Just curious if you had to provide records of your weigh ins for years prior?

[terry1118 1,274]

Terry - Just curious if you had to provide records of your weigh ins for years prior?

No, because out was BCBS who paid for all my copays with Miriam Hospital's Optifast program. Does your plan require documentation?

[gabrielle2014 38]

Yes it says documentation but someonen else that I met that had it out of Wareham and has BCBSRI said she just gave the doctor's office a list of her WW and other attempts and that seemed to be enough. She said Dr. Kruger's office handled everything for her. And she actually gained a bit, wore ankle weights, and the nurse even let her hunch down a bit. LOL!

I'm thinking my afib and arthritis have to contribute to the overall case if I'm at or really close to 40 BMI.

[terry1118 1,274]

As I said, Wareham is AWESOME. :-) They know how to help you get the job done, if it's it's what you really want and need. :-)

[jenn2752781 13]

So far I have to agree wareham is awesome!!!! Start the classes on sept 3

[gabrielle2014 38]

Jen - So you go through the program, if you qualify, and then you go for insurance approval? Did they give you an idea as to whether you would be approved by your insurance? I think you said they didn't?

[jenn2752781 13]

I was told that my ins doesn't have too many restrictions and is pretty easy to work with and that they don't get a whole lot of people being denied

[terry1118 1,274]

Jen - So you go through the program, if you qualify, and then you go for insurance approval? Did they give you an idea as to whether you would be approved by your insurance? I think you said they didn't?

Of course they can't tell you if you WILL qualify. One of the most important purposes of the testing is to see if you have no underlying problems that would make the surgery dangerous. In the process they may find out something else that having the surgery would help. Psych evals determine if you have eating disorders or emotional issues that need to be addressed before surgery so that you will have the best chance of success after. In the case of ins requirements for documented weight loss history, it's to prove you have tried unsuccessfully to lose weight conventionally and are not trying using WLS as your first choice. Ultimately, the insurance co reviews all the data and determines if you meet the their criteria. Getting denied doesn't mean a definite 'No' either. It just means that more testing or documentation is required. Or maybe treating a health issue to make it safer. The doctors and support staff at Wareham have over 10 years of WLS experience, have done well over 3000 surgeries, and have vast experience dealing with all manner of local health insurance companies so they are usually confident they can provide whatever is needed for approval. But, no, there is no absolute 'guarantee'...

It seems to me that insurance companies will approve the surgery because, though surgery is expensive and has risks in an of itself, the long-term costs of obesity and it's asociated health risks are much more expensive over all.

[gabrielle2014 38]

Thanks Jen - When I called the doctor's office to make an appointment she said that I know if I 'qualify' that first appointment and then got through the process and then need approval from the insurance company and then clearance from the medical tests. But I'm happy to know they will be able to help me through it and that everyone that has been there seems to really love them.