First Health Insurance (Possible Self Pay)

[AshRae84 0]

Ok, guys, I need some advice. When I went into my Dr's office for my first consulation (Which was on 4/27/07), I went in basically prepared to self pay.

Well first of all I have to submit to my insurance company, just to make sure they won't pay. They have a list of things my insurance company requires. (Pulmonology, Cardiology, Psych, and 3 *or 6* month supervised diet)

Well I have dieted all my life (Trimspa, Ediets, Weight Watchers, the plain and simple 'cutting back') and have always lost, but then gained the weight lost, and then some.

I have no documentation of this from any of my physicians.

My concerns are these, in my insurance packet (I have First Health Insurance), it states that Gariatric procedures are excluded unless deemed medically necessary, by a comorbidity. Well I have no medical problems, (I'm not a diabetic, my sugars are fine, my blood pressure is fine, etc.) I have a family history of heart disease, diabetic, etc. and I know that if I don't do something about my weight now it will be inevitable that I will eventually suffer from all of these things, and then some.

I have no issues losing weight, it's just keeping it off. So my question is if I go through this diet program, and weight another 6 months, what are the odds of my insurance company STILL Denying me because I CAN lose weight, and I have no comorbidities.

Sorry if this seems like rambling, it's just hard to explain, and I have no idea what to do...

:help: ~*Ash*~:help:

[AshRae84 0]

Just bumping this up, I am desperately needing advice... I'm seriously stressed out about all this stuff.

~*Ash*~

[Alexandra 55]

Ok, guys, I need some advice. When I went into my Dr's office for my first consulation (Which was on 4/27/07), I went in basically prepared to self pay.

Well first of all I have to submit to my insurance company, just to make sure they won't pay. They have a list of things my insurance company requires. (Pulmonology, Cardiology, Psych, and 3 *or 6* month supervised diet)

Well I have dieted all my life (Trimspa, Ediets, Weight Watchers, the plain and simple 'cutting back') and have always lost, but then gained the weight lost, and then some.

I have no documentation of this from any of my physicians.

My concerns are these, in my insurance packet (I have First Health Insurance), it states that Gariatric procedures are excluded unless deemed medically necessary, by a comorbidity. Well I have no medical problems, (I'm not a diabetic, my sugars are fine, my blood pressure is fine, etc.) I have a family history of heart disease, diabetic, etc. and I know that if I don't do something about my weight now it will be inevitable that I will eventually suffer from all of these things, and then some.

I have no issues losing weight, it's just keeping it off. So my question is if I go through this diet program, and weight another 6 months, what are the odds of my insurance company STILL Denying me because I CAN lose weight, and I have no comorbidities.

Sorry if this seems like rambling, it's just hard to explain, and I have no idea what to do...

:help: ~*Ash*~:help:

If the only criterion you DON'T meet is the lack of a co-morbidity, you may have grounds for an appeal even if you're denied the first time. You didn't say what your BMI is, but if it's over 40 the medical guidelines say you don't need a co-morbidity for bariatric surgery to be deemed medically necessary. If your carrier follows generally accepted medical practices and procedures, or those of the American Medical Association (check the fine print in your contract), they can't just arbitrarily decide that their medical criteria can be different from those used by the rest of the medical community.

If insurance coverage is really important to you and your BMI is above 40, I'd say definitely go through the steps for precertifying. If bariatric surgery is not excluded entirely, then the case rises and falls on whether the treatment is medically necessary for you. No carrier wants to be sued for denying necessary treatment, so you will have an excellent case for appeal.

If, on the other hand, your BMI is between 35 and 40, your carrier is simply sticking to the letter of the guidelines used by doctors nationwide, and they are within their rights to say no. But the surgeons I know say that it's virtually impossible for someone that much overweight NOT to have a comorbidity--it just has to be found. Is your PCP willing to help you with this? You might need additional testing, etc.

It can take patience and persistence, but not only might you win yourself, you will also be making it that much easier for the next person. You will never know unless you try. Good luck!!

[AshRae84 0]

My BMI is actually 52. But I'm still fairly young, and haven't really developed any issues YET. But I think it's only a matter of time.

I'm just afraid I will go through all this, and still end up having to self pay.

And just like anyone else, I wanted to have the surgery last week, ya know? :-P

It's so frustrating.

Does it seem right that they would require me to do all the pre op procedures (Cardio, Pulmonology, Psych), and the supervised diet before even submitting it to insurance?

~*Ash*~

[AshRae84 0]

As if I wasn't stressed enough, I now find out that apparently my insurance has a 12 month pre-existing on ANYTHING, so for 12 months, they won't pay for anything at all. (And my insurance with my new employer just went into effect on May 1st...) so it looks like it's more than likely definitely going to be a selfpay route for me...

~*Ash*~

[Alexandra 55]

My BMI is actually 52. But I'm still fairly young, and haven't really developed any issues YET. But I think it's only a matter of time.

I'm just afraid I will go through all this, and still end up having to self pay.

And just like anyone else, I wanted to have the surgery last week, ya know? :-P

It's so frustrating.

Does it seem right that they would require me to do all the pre op procedures (Cardio, Pulmonology, Psych), and the supervised diet before even submitting it to insurance?

~*Ash*~

Actually, it does make sense. All those tests are to determine IF you are medically qualified for surgery. The request for precert wouldn't be complete without them, and the carrier wouldn't even look at it.

But with a BMI of 52 it's unconscionable that your carrier would say you are not medically qualified. That is a very strong ground for appeal.

As if I wasn't stressed enough, I now find out that apparently my insurance has a 12 month pre-existing on ANYTHING, so for 12 months, they won't pay for anything at all. (And my insurance with my new employer just went into effect on May 1st...) so it looks like it's more than likely definitely going to be a selfpay route for me...

~*Ash*~

If you had insurance prior to May 1, you would not be subject to that pre-existing condition exclusion. You just have to show that you had prior coverage.

[AshRae84 0]

I did have insurance, but it lapsed between January and May. And apparently that gap is significant enough for them to deny me everything for a year. (The sleep Center found this out for me.)

Right now Im just really looking into proceeding with the self pay option.

But I can't thank you enough for your help in this matter. I have been such a basketcase this weekend stressed over this. (Thinking I might need to up my Lexapro before this is all said and done. :-P)

~*Ash*~

[jeejee 0]

Alexandra,

You seem like an expert on this, and I respect the advice that you have given to others thus far. My BMI is 38, and was diagnosed earlier this year with Asthma, then sleep apnea. I also suffer from acid reflux, and dizzy spells. I have Aetna EPO, and they suggest that I have a BMI of 40 or a BMI higher than 35 between 40 w/ comorbidities. Any suggestions? My doctor submitted my pre-cert on May 4th. I am really nervous about this. I'm from New York by the way

[Alexandra 55]

Hi jeejee!

Aetna does follow the medical guidelines for qualifying, which are what you mention above. You do have at least one weight-related comorbidity, the sleep apnea, and I'm sure your doctor was able to make the case that your other medical conditions are also affecting your health and need to be considered. If your plan covers bariatric surgery for medically qualified patients, AND you have met all their qualifying requirements (do they still require the six-month supervised diet?) and had all the tests, you should be OK.

Your doctor is really the expert on this--or, at least, those people in his office who handle these things. If they thought it was worth submitting for pre-cert, you have a very good chance of success.

[anonemouse 1]

Hey, I also have First Health. They literally approved me within 2 days, once they had all the documentation. That is what took the longest. I finally got the rest of my documentation sent to them on a Friday and I was approved the following Monday. They are good about approvals, but they require you to jump through hoops to get it. I did my documented weight loss diet in 2005, long before I ever considered getting the lap-band. What took longest was getting the rest of the documentation. Between getting appointments with all my doctors to have them write letters for me, I had to make appointments with a pulmonologist, psychologist, and nutritionist, and have an upper GI done.

You really need to check with the insurance company to see which surgeons are in their network, though. There were only two in my state that they would pay for.

[musicalmomma 1]

Our insurance, Anthem BC/BS ( the BS should stand for bull sh*t) denied my husband because his BMI is TOO HIGH!!!! They won't cover lapband if your bmi is over 50!!! The lapband company is appealing it for him right now. If he gets denied again, he's going to have GB and that's going to cost them about twice as much! Where's the logic in that?

[jeejee 0]

Thanks Alexandra!

[srsalas 0]

Hey, I also have First Health. They literally approved me within 2 days, once they had all the documentation. That is what took the longest. I finally got the rest of my documentation sent to them on a Friday and I was approved the following Monday. They are good about approvals, but they require you to jump through hoops to get it. I did my documented weight loss diet in 2005, long before I ever considered getting the lap-band. What took longest was getting the rest of the documentation. Between getting appointments with all my doctors to have them write letters for me, I had to make appointments with a pulmonologist, psychologist, and nutritionist, and have an upper GI done.

You really need to check with the insurance company to see which surgeons are in their network, though. There were only two in my state that they would pay for.

WOW! I Have First Health as well (ppo) their were 2kinds my hubby signed up for the better option one.I read that handbook a100x(ppo plan A)I think;he works for ttx railroad anyway...I didnt see were it would cover;really it said not for weight loss clinics or supplements... so I wondered... is this a clinic or a surgery processes,I called the insurance,and they said Well...If a Doc thinks it's necassary. So I called to have an appt.06/07/07 I already had my doc. give me my med.recs.I sooooo hope it will get paid for my bmi is 38.3 I have pre-diabetes,high cholesteral,borderline high bloodpressure....any thoughts?

Sabrina

[srsalas 0]

I had my Doc.visit 06/07 and I didnt see a Doc.it actually was a nurse practitioner I think.anyway I know exactly what your talking about.First

Health wanted a 6mo.supv.diet,cardio stress test,a visit with a nutritionist,physc.eval. blood work,and a sleep test omg.but I have 6mo.

To get everything,I was so hoping it would be sooner,My face hit the

Floor when I got the list.

Sabrina

[srsalas 0]

I found out 06/14/07 I may not need to wait for the 6mo. diet. One of the girls at the clinic call-ed to tell me. See I noticed on one web-site that First Health,You need a physc.eval. and a History and physical from pcp documenting any

co-morbidities. So when I told the receptionist

she said she would check. They had a paper with their criteria for First Health a long one I might add...She said I may not need all the other things which was listed previously.She had recieved a phone call from the insurance people on the Dr's. end and found out what I needed. So it may not take as long as I thought.

"I say" always ask questions, it never hurts.

Sabrina:clap2: