Confused about insurance requirements for bariatric surgery

[rocal6356 1]

Hello everyone,

I have decided to see a patient advocate at TrueResults in Phoenix to see if I am qualified for the gastric sleeve. I gave all my insurance information to them before my appointment (I have Highmark BCBS through my employer, Centene Corp). The patient advocate informed me that they verified my coverage and that I meet all the requirements for a bariatric surgery. However, my BMI is under 40 and I do have one of the co-morbidity mentioned in the insurance requirements which is HBP. My dilemma is that the patient advocate said that I am required to be on two blood pressure pills in order to qualify - which I am - but the customer service people at Highmark BCBS keep telling me that I need to be on three HBP pills in order to qualify (they even sent me a hard copy of the requirements). I don't know who is right and I don't want to start this journey and to find out that I am denied. Has anybody else experience something like this ?

I would think that the insurance people at TrueResults have accurate information, but I doubt it right now. The customer service rep at Highmark gave me the requirements for Highmark BCBS in general, but I know every employer might override these general requirements. Please help ! Thank you.

Isabella

[katanne 215]

The program coordinator at my surgeon's office was more knowledgeable about what my insurance covered than the insurance rep I spoke to on the phone! Have you been in contact with a surgeon yet? They may be able to be of great assistance to you in this matter.

[missvee 28]

Every insurance company has their own general requirements but what would make the difference is what the plan your employers chose states. Sometimes the insurance company as a whole has variation coverage but the specific plan you have may not, I would call again and ask if they are quoting your plan or general benefits

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[rocal6356 1]

Thank you both, katanee and missvee, for your answers. I feel that I have hard time with my insurance's reps. The information they gave me is about general benefits since I wett on highmarkbcbs.com and got the requirements from there without logging into my specific group plan. I think I will contact the insurance rep at TrueResults where I suppose to have the surgery. Their patient advocate reassured me twice that I am ok in regards to surgery coverage unless I lose weight during the 6 months dr. supervised diet and go under the BMI of 35.

[Sarah 82 9]

The patient advocate with true results is probably not the person that's actually in charge of getting your prior authorization approved. I used True Results in Dallas and my advocate told me I was good to go but it was a different person that called to verify my requirements etc. My suggestion is to call your insurance again and ask for specific benefits for your plan. I work with insurance as part of my job so if you'd like me to check into it for you I can one day this week from work. Just send me an email with your full name, DOB, and id#. sseelbach@live.com

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[rocal6356 1]

Thank you so much for your tremendous help. You should have received an email from calipsog@yahoo.com with the information requested.

[ld33 94]

I would definitely check with the person who submits the insurance. My patient rep (at the surgery center) picks up the phone to call the insurance rep to see if certain documentation is acceptable

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