How to find out what your insurance requires to cover your surgery

[2goldengirl 2,076]

In the short time I've been on these boards, the most common insurance question is "will XYZ Health Plan approve me?"

Here is how to find out BEFORE you move forward.

1. Find your insurance card. Call the toll-free number on it (member or subscriber services) and ask specifically whether your plan has any exclusion for bariatric surgery. It's rare, but it does happen. If you have your "Evidence of Coverage" or "plan documents" booklet shoved in a drawer somewhere, any exclusions will also be in that booklet.
2. Sometimes the person on the phone needs to look up the surgery by Procedure code, or CPT code. The code for a gastric sleeve is 43775.
3. If you don't already know that your deductible or copay is for a hospital stay, the time to ask is now.
4. While you're on the phone ask them to send you a copy of their criteria for bariatric surgery. Most plans will do this; in California, the law says they have to do this.
5. If you have trouble getting them to send it to you, or you simply don't want to wait for the mail, go to your good pal Google. Google "nameofinsurancecompany plantype medical policy bariatric surgery" for example, "BCBSNJ PPO medical policy bariatric surgery" . I did that, and got this link: https://www.horizonblue.com/providers/policies-procedures/utilization-management/prior-authorization-lists/ppo The criteria themselves aren't on this page; but it does tell me that prior auth is required for bariatric surgery. OK, where to go from here? Over on the left, I see a link for "policies". I click that, and there it is: "Medical Policy Manual". There is a disclaimer page there, and then three other tabs. I click the "alphabetical" tab, and looky there, a link to the bariatric surgery policy. Here is that link: https://services3.horizon-bcbsnj.com/hcm/MedPol2.nsf this particular example is one that takes more steps, a lot of plans have a direct link and whammo, you can just pull up the policy.
6. Have a look at the top of the policy and you will see the "last reviewed" date. This can be important if your plan has a recently reviewed policy and your PCP and/or surgeon's office isn't aware of any changes. it can make you crazy if someone you're dealing with insists that the policy is different than what you see in front of you. I am having this problem right now, myhealth plan has recently dramatically changed their policy and made the whole process much more simple - but even after sending a copy to my surgeon's office, they are having trouble wrapping their heads around the change. I get it, it's a big change, and it's a patient who is better informed than they are.
7. Be aware that your surgeon or bariatric clinic may have requirements for all their patients in addition to those set by the insurer. These are done in order to assure you have the most successful surgery possible. Your surgeon has the right (and responsibility) to require that you adhere to a pre/postop diet, get certain preop testing done, etc.

I hope this is helpful, I happen to have been in the business of getting services of all types approved for twenty years. It's SO much easier to get your hands on this information than it once was!

[newmebithebypass 713]

there is also another thing most people dont know about. some insurances have a bariatric cordinator. mine dose i have united health care ppo i called and asked about my coverage for bariatric surgery and they enrolled me in a program with a nurse and a whole healthcare team that works with bariatric patients so yeah definatly go that rout if you can

[2goldengirl 2,076]

there is also another thing most people dont know about. some insurances have a bariatric cordinator. mine dose i have united health care ppo i called and asked about my coverage for bariatric surgery and they enrolled me in a program with a nurse and a whole healthcare team that works with bariatric patients so yeah definatly go that rout if you can

I wasn't sure whether health plans did this - I'm in CA and most health plans delegate case management to medical groups. In the group I work for, anyone with a referral from their PCP for bariatric-related services gets a case manager. The truly fortunate get...me! We contact those members as soon as they get involved in the process, go through health plan requirements, answer any questions, and make follow up calls after surgery. We do have some comprehensive programs in the area that duplicate a lot of this, and we leave it to the member whether they'd still like a case manager.

[Kimba Maria Wiggins 81]

I live in NY and I called Medicaid 3 times before I made my first appointment with the doctor to make sure sleeve gastrectomy would be covered (which was yes). I have Straight Medicaid and the doctor's office I'm going to also ran my Medicaid ID number while I was on the phone so if there would've been an issue, I would've been told right away.

Edited June 21, 2016 by Kimba Marie Angelina Wiggins

[Mapleleaves Welch 4]

hi I have Medicaid and medicare I am going to have appointment with surgeon july 8

I am wondering if my insurance will let me have surgery and also I'm 62 am I too old

[Christinamo7 4,042]

that's very helpful.

when I went to my initial seminar we sat down with the insurance/referral person who already had our policy looked up and told us what our copay and everything would be. what the requirements for approval were.

it was very helpful to me as far as planning my surgery.