Ok Guys, I Need Some Serious Help!

[lovealways 287]

Ok. So here goes. I'm going to try to explain this as best as possible. My BMI is 46, and I have sleep apnea and some form of arthritis we're still in the process of determining. I have completed all of my pre-op testing and just had my 3rd weigh in with my PCP.

I have United Healthcare Community Plan in NY, which is a Medicaid HMO. They cover gastric bypass fully with prior authorization and as long as it is medically necessary. My surgeon's office tells me I need 6 months of supervised diet, so I have been doing that....BUT, I have called UHC Community Plan multiple times and when I ask about requirements, they say there is none listed, but the surgery has to be deemed medically necessary. They said some type of documentation of a physician assisted or diet with a nutritionist HELPS approval, but is not necessary. They said there is no mention of how long it needs to be done, and just mentioned anything helps to prove medical necessity.

So here's the thing. Who do I believe??

Another thing. I have a crazy, crazy schedule with graduate school, working, interning, etc. and I REALLY need this surgery during winter break anytime between Dec. 19 to Jan. 19.

I just emailed my patient advocate and asked her if I can submit a MONTH early in November. That will give me ONLY 5 months of consecutive weigh-ins with PCP. JUST in case, I will make a December appointment (my 6th weigh-in) just to be SURE in case I am denied.

My surgeon is usually very booked and it takes a long time to get an appointment for surgery, etc. etc.

I want to submit in November, a month early before my 6th month weigh-in, but is this wise given the scenerio above?

Who do you believe? Your surgeon's office, who has experience in getting people approved, or the doctor's office? Am I making a mistake submitting a month early?

THANK YOU!

[rabrijumo 140]

I wish I could help more but here is my two cents. It can't hurt to try and submit early worse thing that can happen is they say no and you wait the extra month. Second I recommend sitting down with the surgical coordinator at the surgeons office and ironing out why they say the insurance reuirement is 6 months when the insurance company says they do not have that or any requirement. They usually have lots of experience getting people approved and maybe they have run up against rejections.

[lovealways 287]

I wish I could help more but here is my two cents. It can't hurt to try and submit early worse thing that can happen is they say no and you wait the extra month. Second I recommend sitting down with the surgical coordinator at the surgeons office and ironing out why they say the insurance reuirement is 6 months when the insurance company says they do not have that or any requirement. They usually have lots of experience getting people approved and maybe they have run up against rejections.

Thank you! I'm so worried i'll be denied, but we'll see what happens.

[BBdoodle 483]

I was lucky that my insurance covered everything and I did not need to be on any diet before hand. MY surgeon's office had a insurance coordinator that I worked with when getting all my pre-op testing done etc. they also do the insurance submission as well. I had high b/p and cholestrol and my BMI was 37 so I was worried that I would be denied because of my low BMI. My surgeon had a form letter that I was to give to my regular physican that states that it is medical necessary, and that I have been on supervised diets in the past that have not worked etc. etc. Basically it said all the things that the insurance wants and needs to hear but it just needed to be signed my my regular physican. I had to go for a sleep apena test as well but everything was ok and I did not have sleep apena. Once I got all my ducks in a row then the coordinator submitted to the insurance and I was approved in like 4 days. From what I understand the letter from my regular doctors is/was key in approval. If you want a draft of the letter friend me and I will send you a copy...its pretty convincing

[lovealways 287]

I was lucky that my insurance covered everything and I did not need to be on any diet before hand. MY surgeon's office had a insurance coordinator that I worked with when getting all my pre-op testing done etc. they also do the insurance submission as well. I had high b/p and cholestrol and my BMI was 37 so I was worried that I would be denied because of my low BMI. My surgeon had a form letter that I was to give to my regular physican that states that it is medical necessary' date=' and that I have been on supervised diets in the past that have not worked etc. etc. Basically it said all the things that the insurance wants and needs to hear but it just needed to be signed my my regular physican. I had to go for a sleep apena test as well but everything was ok and I did not have sleep apena. Once I got all my ducks in a row then the coordinator submitted to the insurance and I was approved in like 4 days. From what I understand the letter from my regular doctors is/was key in approval. If you want a draft of the letter friend me and I will send you a copy...its pretty convincing [/quote']

Oh thank you so so so much! You can email me the letter at jmclingo@gmail.com. I think basically what my insurance wants is to demonstrate that the surgery IS medically necessary by having a PCP state that it is. It would be so helpful if you can email me the form I think I really will benefit from having something my pcp can look over and sign. Thanks again

[lovealways 287]

Thanks for responding guys I think I'll just go ahead and submit in November after my 5th month weigh in. ::fingerscrossed::

[Winter84 35]

Thanks for responding guys I think I'll just go ahead and submit in November after my 5th month weigh in. ::fingerscrossed::

Honestly some surgeons , just like getting a pay check , I went to my surgeons office a number of times just to get weighed or to give me paper work for test I have to take when in reality he could of gave me everything I needed to get the ball rolling , not one paper every 3 weeks .... Best wishes

7*10*12

[DLCoggin 1,788]

It's my understanding that most insurance companies require a "letter of medical necessity" and that it usually comes from your PCP. I absolutely would go ahead and submit it to the insurance company in November if not sooner (based on the information you have, there doesn't appear any reason not to submit it immediately if it works with your schedule). Even if they approve it right away there will still likely be a delay for getting the surgery scheduled. As already pointed out, the worst that could happen is that they reject it until you meet "X" requirement. You're getting close!!!

[lovealways 287]

It's my understanding that most insurance companies require a "letter of medical necessity" and that it usually comes from your PCP. I absolutely would go ahead and submit it to the insurance company in November if not sooner (based on the information you have' date=' there doesn't appear any reason not to submit it immediately if it works with your schedule). Even if they approve it right away there will still likely be a delay for getting the surgery scheduled. As already pointed out, the worst that could happen is that they reject it until you meet "X" requirement. You're getting close!!![/quote']

Thanks so much dl...great advice as always. I'll submit s month early and let you know what happens. Keep your fingers crossed for me...I neeed this.

[ColoradoChick 33]

I would love to see the form letter for medical necessity. Would you share? Thanks!!