Need help understanding insurance coverage

[pephlin 0]

Ok, I went to an information seminar, met with the patient advocate and she told me that I was covered and proceeded to tell what the requirements were, BMI of 40, 5 year weight history at a BMI of 40 or a BMI of 35-39 with 2 comorbid conditions. I ciouldn't believe this is what my insurance would ask for so, I called them. I spoke to a representative and they told me that I only needed a BMI of 40+ or 35-39 with one or more co morbid conditions. The advocate said that "the insurance" people that work for true results know a lot about insurance and they know what the requirements are. She told me to get the info, in writing and she would look over it. So, I called my HR dept. and retrieved a copy of the "Booklet of Certificate" which explains all of the coverage that my insurance company covers. In a nutshell it states that charges are covered if a person is severe or morbidly obese, and then it give the definitions of what those are. There is no mention of additional requirements. Is this correct??? If there are requirements where would I find them???

HELP!!!

[ccarter8219 0]

Ok, I went to an information seminar, met with the patient advocate and she told me that I was covered and proceeded to tell what the requirements were, BMI of 40, 5 year weight history at a BMI of 40 or a BMI of 35-39 with 2 comorbid conditions. I ciouldn't believe this is what my insurance would ask for so, I called them. I spoke to a representative and they told me that I only needed a BMI of 40+ or 35-39 with one or more co morbid conditions. The advocate said that "the insurance" people that work for true results know a lot about insurance and they know what the requirements are. She told me to get the info, in writing and she would look over it. So, I called my HR dept. and retrieved a copy of the "Booklet of Certificate" which explains all of the coverage that my insurance company covers. In a nutshell it states that charges are covered if a person is severe or morbidly obese, and then it give the definitions of what those are. There is no mention of additional requirements. Is this correct??? If there are requirements where would I find them???

HELP!!!:thumbup:

The requirements are not always posted in your certificate booklet. Call your insurance company and ask them to mail you a copy of the requirements. What insurance company do you have?

[pephlin 0]

I have United Healthcare EPO choice

[ccarter8219 0]

I have United Healthcare EPO choice

Go to the following link:

www.unitedhealthcareonline.com

then choose:

tools & resources - Policies & Procedures.

Then choose:

Medical Policies ( on right side of screen under Policies)

then read & agree with their terms and conditions.

then choose:

Bariatric surgery.

This should give you all the info you need.

Coverage Rationale

Gastric bypass (Roux-en-Y; gastrojejunal anastomosis), vertical banded gastroplasty (gastric banding; gastric stapling), adjustable gastric banding (laparoscopic adjustable silicone gastric banding), biliopancreatic bypass (Scopinaro procedure), biliopancreatic diversion with duodenal switch, and laparoscopic bariatric surgery are proven in adults for the treatment of clinically severe obesity as defined by the National Heart Lung and Blood Institute (NHLBI) who are:

1. Morbidly obese (BMI of 40 or greater)

2. Severely obese (BMI 35-39.9) with at least one of the following obesity related comorbidities

Cardiovascular disease including stroke, myocardial infarction, stable or unstable angina pectoris, coronary artery bypass or other procedures

Hyperlipidemia uncontrolled by pharmacotherapy

Type 2 diabetes uncontrolled by pharmacotherapy

Hypertension uncontrolled by pharmacotherapy

Moderate to severe sleep apnea with a respiratory disturbance index (RDI) of 16 to 30 (moderate) or apnea-hypopnea index (AHI) >30 (severe) as documented through the completion of a laboratory based polysomnography.

This is just a small amount of their information. If you live in maryland they have specific criteria just for them.

You can e-mail me if you have any questions. my e-mail address is ccarter8219@live.com

[TSB 1]

My surgeon has a whole set of his own requirements that seem to have nothing to do with what my insurance company requires. I won't even be submitted for insurance approval until I have satisfied the surgeon's requirement.

[pephlin 0]

Go to the following link:

www.unitedhealthcareonline.com

then choose:

tools & resources - Policies & Procedures.

Then choose:

Medical Policies ( on right side of screen under Policies)

then read & agree with their terms and conditions.

then choose:

Bariatric surgery.

This should give you all the info you need.

Coverage Rationale

Gastric bypass (Roux-en-Y; gastrojejunal anastomosis), vertical banded gastroplasty (gastric banding; gastric stapling), adjustable gastric banding (laparoscopic adjustable silicone gastric banding), biliopancreatic bypass (Scopinaro procedure), biliopancreatic diversion with duodenal switch, and laparoscopic bariatric surgery are proven in adults for the treatment of clinically severe obesity as defined by the National Heart Lung and Blood Institute (NHLBI) who are:

1. Morbidly obese (BMI of 40 or greater)

2. Severely obese (BMI 35-39.9) with at least one of the following obesity related comorbidities

Cardiovascular disease including stroke, myocardial infarction, stable or unstable angina pectoris, coronary artery bypass or other procedures

Hyperlipidemia uncontrolled by pharmacotherapy

Type 2 diabetes uncontrolled by pharmacotherapy

Hypertension uncontrolled by pharmacotherapy

Moderate to severe sleep apnea with a respiratory disturbance index (RDI) of 16 to 30 (moderate) or apnea-hypopnea index (AHI) >30 (severe) as documented through the completion of a laboratory based polysomnography.

This is just a small amount of their information. If you live in maryland they have specific criteria just for them.

You can e-mail me if you have any questions. my e-mail address is ccarter8219@live.com

Thank you:rolleyes2: