Insurance Approval ?!

[ladycharizar 44]

Hey Guys & Gals !

Today was my last NUT appointment and I'm officially psyched and nervous at the same dang time. My surgery date is August 7th; i have to wait 15 days to wait for my approval, but for some reason I'm nervous they won't accept it. I have the Empire Plan (NYSHIP/United Healthcare) has anyone had any experience positive or negative with this insurance ? I'm open ears ! [emoji4]

[JT2002TJ 170]

15 hours ago, ladycharizar said:

Hey Guys & Gals !

Today was my last NUT appointment and I'm officially psyched and nervous at the same dang time. My surgery date is August 7th; i have to wait 15 days to wait for my approval, but for some reason I'm nervous they won't accept it. I have the Empire Plan (NYSHIP/United Healthcare) has anyone had any experience positive or negative with this insurance ? I'm open ears !

I have NYSHIP as well, why do you think they wont cover you? The NYSHIP group is very big, which is why the coverage is more than most. As long as you went to a surgical group with experience with NYSHIP, you met the prerequisites, I'm not sure why they would deny you.

My surgical group said, they never have problems with NYSHIP, including if patients have slight weight gain or loss during the 6 month monitored diet.

[ladycharizar 44]

Because I didn't lose 20% of me weight like I was supposed to , I gained and lost the weight so like 6 pounds. That's the only thing I'm nervous about.

[ladycharizar 44]

My *

[JT2002TJ 170]

My NYSHIP did not require a mandated weight loss amount... Are you sure that wasn't a surgical group mandate?

[ladycharizar 44]

Well they said my insurance needed me to lose 20 lbs, I guess to show I was determined to go through this life change. Although when I was talking to my NUT she said they'd still approve it since I didn't gain more weight than my starting number.

[JT2002TJ 170]

Well, hopefully your NUT is correct. My surgical group just said don't gain or lose too much. My coordinator said some insurance companies will deny if you are 1 lb heavier than your initial weight, others require a set amount of weight, but mine had nothing specifically documented. She said she has put many people through with my same insurance (from my same agency) and never had an issue with weight.

[ladycharizar 44]

Ahh okay, yeah thanks. So you had your surgery I'm guessing then ?

[JT2002TJ 170]

Just now, ladycharizar said:

Ahh okay, yeah thanks. So you had your surgery I'm guessing then ?

No. Not yet. I have my 4th weigh-in this month (2 weeks), so next month they will submit my packet. I do believe my coordinator though, because their entire job is based on getting their patients through the process and approved. The 2 required dr's visits are peanuts (initial consult and pre-surgery visit), and not even worth her time, so their entire motivation is to have you actually go through he surgery.

I did do my weigh-ins with them and not my NUT, so they did gain the benefit of 6 additional visits.

What was your starting BMI? Mine was 40.3, I am down about 9 lbs since then. I have the full list of comorbidities... I have high BP, Cholesterol, and 2 years of sleep apnea with 94%+ utilization. So, technically I was already above the no need for comorbidities threshold.

[ladycharizar 44]

I have mild sleep apnea, I'm getting my machine soon. I was lucky in doing a sleep study a week before my last appointment so I know that wont hold me back. My BMI was like 58.7 if I remember correctly and I had hypertension as well. I was otherwise pretty healthy other than being overweight. I have sciatica and herniated discs as well as GERD plus PCOS; so my issue list goes on and on. My starting weight was 405.7 throughout the 6 months it went up and down, I one time even went up to 390 but immediately gained it back; so much that I weight 408.00 my 5th appointment. I kicked into gear and lost the 6 pounds so for my last appointment I was 402.00. I've really been through the ringer during this long process.

[JT2002TJ 170]

2 minutes ago, ladycharizar said:

I have mild sleep apnea, I'm getting my machine soon. I was lucky in doing a sleep study a week before my last appointment so I know that wont hold me back. My BMI was like 58.7 if I remember correctly and I had hypertension as well. I was otherwise pretty healthy other than being overweight. I have sciatica and herniated discs as well as GERD plus PCOS; so my issue list goes on and on. My starting weight was 405.7 throughout the 6 months it went up and down, I one time even went up to 390 but immediately gained it back; so much that I weight 408.00 my 5th appointment. I kicked into gear and lost the 6 pounds so for my last appointment I was 402.00. I've really been through the ringer during this long process.

Ah... Here we go. I believe if your BMI is over 50, they add additional restrictions. I believe it is the surgical group and/or the hospital where you will have the surgery. They really want patients under a BMI of 50 for anesthesia purposes. It also is a risk of complications. My group said they do this.

I honestly do not believe it is a NYSHIP requirement. So, my opinion is the insurance company will approve it, but it will be up to the surgeon if he/she will. I believe when approved by the insurance company, you have up to 2 years to complete the procedure, so at worst, your surgeon may ask you to continue the diet to lose more, at best, you will be approved and scheduled as is.

[ladycharizar 44]

Ahh my hospital is Greenwich Hospital.

[JT2002TJ 170]

8 minutes ago, ladycharizar said:

Ahh my hospital is Greenwich Hospital.

I suggest calling your coordinator and asking if the weight loss was an insurance requirement or a surgical group/hospital requirement. I have a feeling it will be the latter.

The medical industry is so much tied to patient outcomes. Surgeons really care about their complication rate, as it is what drives patients to them, and what determines future employment. This is why they put restrictions on smoking, it has nothing to do with the insurance companies, just complication rates.

If this is the case, it will be up to the surgeon. If they do approve they may warn you that if they even see the slightest issue doing it laparoscopically, they will open you up. The problem with higher BMIs is that the liver is bigger, which makes access to one's stomach more difficult.

I am not trying to worry you. Your best bet is to schedule a quick call with your coordinator, and have a list of questions written down and ready (they are busy, and may try to rush you out of workload not that they are dismissing you).

Edited July 12, 2017 by JT2002TJ

[ladycharizar 44]

I called them already and they haven't received my claim yet for the surgery they said to call back august 3rd which I think is obscene.

[JT2002TJ 170]

Just now, ladycharizar said:

I called them already and they haven't received my claim yet for the surgery they said to call back august 3rd which I think is obscene.

Does "they" equal your coordinator? If so, I'm sorry. Mine has been very responsive. I can even email her and she will respond within 24 hours. When was the last time you went into your surgeon's office? Maybe stopping by may help you?

Did they give you a pre-surgery/bariatric process checklist? Mine has all the requirements.

I am looking at my requirements now. If BMI is over 50 a prescription of Lovenox is required, and if BMI is over 60 there is a requirement of weight loss (20/40/60 they circle what they want). These are surgical group requirements (not NYSHIP).

My surgeon's office knows me by name, I have been there 5-6 times in the past 4 months. To me, this is very helpful, and makes me feel very welcome.