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New here :) Insurance question.

RaynaRayne

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RaynaRayne    3

RaynaRayne
Posted

Hello I'm new year (and scared lol) I've been thinking about getting VSG and while doing all my research I pulled out all my insurance papers and it says it won't cover insurance won't cover "bariatric surgery unless medically necessary". I'm 350+ lbs and I know my BP is high so I do think it would be considered medically necesssay but I'm just wondering if I'm just getting my hopes up. I haven't been to a doctor in years so diabetes may also be something I've developed, I have really bad sciatica and PCOS.

I guess my question is has anyone got their WLS approved with it's not covered but medically necesssay? I know zero about insurance stuff so idk how this all works. Thank you for your time :)

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MSinger    348

MSinger
Posted

Insurance companies will not cover anything unless it's medically necessary. It's confusing wording, but basically, you have a chance at being covered. They usually have a medical policy detailing what criteria you would need to meet in order for your surgery to be approved. Calling your insurance company to find out what criteria need to be met is the first step. Good luck.

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Sosewsue61    3,185

Sosewsue61
Posted

Check the policy online, most have online logons and you can put in your policy number and get the info, or email an ins coordinator through that portal with direct questions about criteria - they all vary greatly. Some require certain bmi w or w/o comorbidities, 2 yrs of records from your PCP that they have discussed weight loss or that you have been on a weight loss program documented by PCP, some only require 3-6 months supervised weight loss, so it is best to investigate w all those questions.

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Luisajfc    402

Luisajfc
Posted

Your bmi should be high. When the number is above 40 ( I believe ) is already a dangerous number. They should approve .


“There will be obstacles. There will be doubters. There will be mistakes. But with hard work, there are no limits.” —Michael Phelps

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RaynaRayne    3

RaynaRayne
Posted

1 hour ago, Luisajfc said:

Your bmi should be high. When the number is above 40 ( I believe ) is already a dangerous number. They should approve .


“There will be obstacles. There will be doubters. There will be mistakes. But with hard work, there are no limits.” —Michael Phelps

I'm almost 100% sure it's well above 40 (which I'm ashamed to even admit that)

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Luisajfc    402

Luisajfc
Posted

I'm almost 100% sure it's well above 40 (which I'm ashamed to even admit that)

What insurance do you have ?


“There will be obstacles. There will be doubters. There will be mistakes. But with hard work, there are no limits.” —Michael Phelps

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eccJuly    11

eccJuly
Posted

Oh I am pretty sure you will qualify. I did with no problem. 40 or higher gets approved and 35 with things like high blood pressure, diabetes, arthritis can get you approved too.


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eccJuly    11

eccJuly
Posted

I have Blue Cross Blue Shield PPO


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RaynaRayne    3

RaynaRayne
Posted

3 hours ago, Luisajfc said:


What insurance do you have ?


“There will be obstacles. There will be doubters. There will be mistakes. But with hard work, there are no limits.” —Michael Phelps

Capital Blue Cross Shield. I called today but they're customer service dept closed at noon so I'll have to call back Monday. I'm just so so nervous because I don't want to get my hopes up...I'm not worried about a dr approving me because I know I meet the requirements it's just having the insurance pay for it is another thing...I don't even mind going through the 6month required meetings, appts, ect if need be.

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RaynaRayne    3

RaynaRayne
Posted

2 hours ago, eccJuly said:

I have Blue Cross Blue Shield PPO

My card has PPO on it as well.

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Luisajfc    402

Luisajfc
Posted

Capital Blue Cross Shield. I called today but they're customer service dept closed at noon so I'll have to call back Monday. I'm just so so nervous because I don't want to get my hopes up...I'm not worried about a dr approving me because I know I meet the requirements it's just having the insurance pay for it is another thing...I don't even mind going through the 6month required meetings, appts, ect if need be.

Before I had blue shield too and I was approve in certain hospitals .. and insurance was no problem, just the requirements of the 6 months with dietician and psychological. Is the doctor job to send the information to your insurance for them to believe you really need this. And with this high bmi would be no problem. You will just need to do the requirements. So have faith.


“There will be obstacles. There will be doubters. There will be mistakes. But with hard work, there are no limits.” —Michael Phelps

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eccJuly    11

eccJuly
Posted

I think you will get approved. But you will have to choose a surgeon and they go through all the hoops of getting you approved. You just relax and concentrate on you. Let them do that work. 😀

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Old2NewMe    73

Old2NewMe
Posted

I'm almost 100% sure it's well above 40 (which I'm ashamed to even admit that)

Don't feel bad. Based on my height and weight (308), mine is a 56! The approved right away based on that. You should be fine


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RaynaRayne    3

RaynaRayne
Posted

13 hours ago, Old2NewMe said:


Don't feel bad. Based on my height and weight (308), mine is a 56! The approved right away based on that. You should be fine

Thank you :)

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