Insurance Question

[hburns89 7]

So I had my first consultation with my surgeon yesterday and the kind lady that I belive is his assistant gave me a packet of all the things that I need to complete for insurance and pre-op purposes. I skimmed through it because I was meeting with the dietician next. When I returned home after my appointment I noticed something I have to provide which is a Letter of Medical Necessity, which I thought was odd since I spoke with my insurance company on three different occasions and got all of the information that I needed in order to be qualified for surgery. Apparently in the letter my PCP needs to give a nod of approval and also a list of comorbidities.....I have not been diagnosed with any of the comorbidities that are listed in my insurance policy (type II diabetes, hypertension, sleep apnea, etc). This frustrates me because I have a 6 month diet that needs to be followed for insurance purposes and I don't want to get to the end of this diet plan and my paper work is submitted just for me to be turned down simply because I haven't yet become very ill. My A1C is in the prediabetic range but I was not diagnosed with it, my blood pressure varies from day to day. My BMI is 44.9, so reading my policy I shouldn't need that letter because my BMI is over 40, it's already medically necessary for me to get surgery without a medical illness. I spoke with my insurance company about this and she informed (with an attitude, repeatedly as well) that this is apart of the policy. But it cleary doesn't state that on the paper work that I have printed out which lists a qualification of for surgery. I even told her that the PCP that I see I've only seen twice in three years (that's how long I've been at my job) and if this PCP decides not to write the letter I mean what than? Which I wouldn't be surprised because she is the type of doctor who would have you change your diet as opposed to taking medicine to prevent a disease, which is wonderful and all but I've been fighting this my entire life and it's starting to get really out of control and I feel like I'm being told that I won't be helped until I develop a illness, I'm 25 years old I thought I was doing the right thing by getting help now instead of waiting. I have CareFirst BCBS MD and they will cover pre-op and post-op as well as the surgery 100% but I kind of feel like this was too good to be true since this letter situation has come to light. Anyone else experience the same thing? Am I panicking for no reason? Any advice would be most helpful.

I will say that I am going to contact my PCP and see if I can get this letter, hopefully it'll all turn out.

[Theresa23 3]

My insurance company customer representatives are clueless when it comes to what the criteria is for wls. I have been told by multiple reps different requirements. Instead I requested a copy of the policy and procedure manual. I also requested a case manager be assigned by my insurance company, so I have one person dedicated to researching any questions I might have. Lastly you can express your concern/confusion with your surgeons office and request that they contact your insurance to clarify. Hope this helps. Good luck!

Edited June 25, 2015 by Theresa23

[TristanNicole 169]

I believe the letter of medical necessity is what the surgeons office supplies when they send in all the paperwork. I think that request is probably just generic and they are accounting for people who have a BMI <40 and do have to have co-morbidities to qualify for the surgery.

[Keke74 16]

Like you , I do not have any co-morbities, but my BMI is over 40. My PCP had to provide a letter of necessity and I was a new patient. After seeing her for 6 months of supervised weight loss, she wrote the letter without a problem and I was approved by my insurance within 2 days after my doctor submitted to them.

[Mobeans63 32]

You may also find that your surgeon may order a sleep study to determine if you have sleep apnea, a bonafide co morbidity. I was extremely surprised to find out I do have it!

[HappyValleyHappy 48]

With your BMI I don't see where you'll have a problem. My pcp sent the letter just stating I was morbidly obese and had been since she started seeing me. Simple.

Don't get panicked. It'll work out.

[ohjul 51]

Just tell your pcp all the diets you have tried and failed- so they can include that in their letter. Hat should help?

[Daisee68 2,493]

With your BMI I don't see where you'll have a problem. My pcp sent the letter just stating I was morbidly obese and had been since she started seeing me. Simple.

Don't get panicked. It'll work out.

I had mine done by my Endocrinologist but he basically said the same thing - unable to sustain markedly improved weight loss. It was pretty simple. If you have only seen her twice, I might make an appt to just go talk to her about this. I'm sure she won't be as opposed as you think.

Not trying to discount your feelings, They are real and I would be (and was) anxious too.

Edited June 26, 2015 by Daisee68

[hburns89 7]

Update:

I contacted my PCP office and explained to the MA my situation and I had asked her if I needed to make an appointment with my doctor or not in order to get this letter written and sent to the surgeons office. She ended up calling me back after talking to the doctor and said yes. Over the next few days she collected information from me regarding my previous weight loss attempts and the doctor wrote the letter, they called me this morning and asked for the surgeons office fax number and it was sent over so yay! Thank you all for your comforting responses, I definitely felt better about my situation after reading them. One step closer!