I could really use some help.

findthenewme · October 23, 2009

Hi I am 35 with a bmi of 38.1 I have horizon bcbs. They require a 6 month period with a nutritionist, therapist visit, bariatric seminar yadayadayada. Well I have been doing all of the requirements.. And then I was told by doc that bcbs prob won't cover me. Here's the worst part- I have 2 degenerated discs no gallbladder fatty liver planters fasciutus achey knees elevated cholesterol boarderline diabetic not to forget IBS and now stress incontinence from this heavy hanging fat roll! How sick do I need to be?? So I have a choice-gain 15 pounds and feel even worse or god knows what or stay this weight and continue jumping through their hoops to just be denied in the end! I wanna scream! I don't have money for selfpay! Any advice?

Enchanted · October 23, 2009

You can always appeal the decision of the insurance carrier to cover the procedure. They probably have guidelines for approval - see if you can get your hands on those. With your related issues, it seems like you should be able to be approved.

Enlist the help of not only your surgeon, but also your general physician, and therapist if you are seeing on. Every little bit helps.

Best of luck to you.

gbakerc · October 23, 2009

Before you go through everything. Find out from your insurance company what their requirements are and make sure that they even pay for WLS. Then you will have a better idea of what you need to do.

Greg

ParrotheadCathy · October 23, 2009

CALL YOUR INSURANCE COMPANY. There should be a customer service number on your insurance card. Ask:

1. is lap band surgery covered by my policy (always good to confirm)

2. is there a minimum BMI requirment? IF SO, WHAT IS IT?

3. I have other health issues. Are any of these considered co-morbidities. [NOTE the answer to this question is probably not, but do ask]

4. Would a letter of medical necessity from my PCP have any impact on coverage?

No gallbladder? Well, frankly, that's good. If you have the surgery you will lose a lot of weight and it's not all that uncommon to hear people who have to have their gallbladder removed because of the weight loss.

Do you have sleep apnea? Often, obese people suffer from sleep apnea. This IS a co-morbidity. The other accepted co-morbidities are diabetes and high blood pressure.

Finally, have you had a consultation with a surgeon yet? The surgeon's office may have other information on getting approved....after all, they file predeterminations for alot of patients!

TSB · October 23, 2009

I agree with the other posters who have advised you do some research on what your insurance company's policy is regarding WLS. As you can see from my stats, my bmi was similar to yours when I started this process. My major/qualifying co-morbidity was high cholesterol. I have BCBS of Maine. Does your doc have a nurse or clinic coordinator? The clinic coordinator at the bariatric center I go to is the one who deals with the insurance companies. Someone like that in the office is often more knowledgable than the surgeon about what the various insurance co. requirements are and about submitting the "right" reports with the "best" wording. In the week or two after I had met the surgeon's pre-op requirements, I was on the phone with the clinical coordinator every other day getting status reports and making sure all the i(s) were dotted and t(s) were crossed.

findthenewme · October 23, 2009

I have seen the surgeon. The coordinator called the insurance and they stated that they wanted documentation. And there r no guarantees. I wonder if I should call the insurance since the dr's office did. I am so pissed!

pixistix · October 23, 2009

Have your doctor's office double-check your height, without shoes on. And maybe slouch a little :closedeyes:

Also, I've read about people who are a few pounds shy of 40 bmi slipping divers weights in their pockets for the weigh-in. They're the size of a pack of cards and come in weights of 5, 10 lbs, etc. Also, people drink a lot of Water, wear heavy shoes, etc.

I know for me, I'm about 5 lbs under 40 bmi and if you're under 40, my insurance only considers extreme comorbidities -- like heart disease and diabetes. But my weigh-in isn't until after the first of the year. And between Thanksgiving and Christmas, I think those 5lbs will just about put themselves on.

Best of luck to you.