Approval Question.

[_bribri1001 62]

My Weight loss clinic had to get an approval from my insurance company first before I could be seen. I got "approved" and I am required to do a 3 month weight loss management before I can go into surgery or get scheduled. I just would like some clarification...

So after the 3 month WLM you still have to submit to the insurance to see if it will be covered? If you meet the weight loss requirements you can still get denied?

How often does that happen?

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[2goldengirl 2,076]

"So after the 3 month WLM you still have to submit to the insurance to see if it will be covered?"

Yes. You got approved for a consult with the surgeon. Your surgeon will have requirements preop (usually diagnostic tests). Your health plan will also have requirements. I don't know what state your in or what kind of insurance you have, so it's a bit hard to generalize. Once you have met both health plan and surgeon's requirements, your surgeon will submit a request to your health plan for approval of the surgery itself.

You would be wise at this point to check with your health plan to find out for certain that WLS is a covered benefit under your plan. Also find out if there is a cap on that benefit (a certain dollar amount that limits your coverage). Some people have found out at the last minute that they had such large deductibles and copays that it would have been less expensive for them to pay out of pocket. It all depends on your plan and your coverage.

I hope this helps!

[_bribri1001 62]

I live in WA. I work for Swedish Medical Group and have insurance through them.

It's a form of BCBS. I am going through my companies weight loss clinic for this surgery. They did say that my insurance does cover the sleeve as well as the bypass but not the lapband (my original decision). I know my insurance covers bariatric surgery, just not weight loss programs (whatever that means). Which might be why the lapband is not covered.... (Not sure).

How often do people get denied by there insurance? I will double check on the cap and call my insurance for price.

I'm just more nervous of the fact that I might do everything asked of me and I still get denied.

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[RILEYSMOM22 344]

I have a good friend that does approvals for BC/BS. While they are not my insurance carrier, it was interesting to see the process from her perspective. She said that she rarely if ever denies bariatric surgery if the BMI is over 35. The rest of the hoops you jump through are just a formality. My surgeons office knew exactly what I needed to do and how to submit each part of the requirements. I needed a letter from my primary doc stating she had supervised my diet and exercise for at least 6 mos. They didn't require a log or any notes. There was no minimum weight to be lost prior to surgery either. Your surgeon's office should be your best resource.