Insurance Question: Why only one requirement?

[Tasia29 9]

Hello, I started my journey the beginning of last year. I am planning to have gastric bypass. Last year when I started my previous insurance (UnitedHealthCare) required 6 month supervised diet. I completed 5 out of six before I decided that at that time not to go forward with the surgery. After a few months I've finally made the decision to have gastric bypass and restart my weight loss journey.

I now have new insurance which is PHCS. I called my insurance to make sure the surgery would be covered and it is covered and my surgeon and hospital are in network with my insurance. I asked them what the requirements were in order to be approved. I was told the only requirement is that the surgery has to be medically necessary. So I guess my question is after my doctor submits my documents to insurance how long does it usually take to get an answer?

Also i really never heard of insurance companies only wanting proof of it being medically necessary. I thought for sure that I would have to redo my 6 month supervised diet. Does anyone else on here have insurance where the only requirement is it to be medically necessary? Does this make it easier or more difficult to be approved?

I meet with my surgeon again on Jan. 25th! I'm really excited to get started again!!

[Hopep4673 120]

not my insurance but i have heard of it being this way... more and more insurances are getting rid of the medically supervised diet requirement. Yes it should make it easier you will likely only need a letter of necessity for your PCP.

However, your surgeon may require more than your insurance like Psych clearance.

Congratulations on your decision and best of luck in your journey.

[Mattymatt 491]

3 hours ago, Tasia29 said:

Hello, I started my journey the beginning of last year. I am planning to have gastric bypass. Last year when I started my previous insurance (UnitedHealthCare) required 6 month supervised diet. I completed 5 out of six before I decided that at that time not to go forward with the surgery. After a few months I've finally made the decision to have gastric bypass and restart my weight loss journey.

I now have new insurance which is PHCS. I called my insurance to make sure the surgery would be covered and it is covered and my surgeon and hospital are in network with my insurance. I asked them what the requirements were in order to be approved. I was told the only requirement is that the surgery has to be medically necessary. So I guess my question is after my doctor submits my documents to insurance how long does it usually take to get an answer?

Also i really never heard of insurance companies only wanting proof of it being medically necessary. I thought for sure that I would have to redo my 6 month supervised diet. Does anyone else on here have insurance where the only requirement is it to be medically necessary? Does this make it easier or more difficult to be approved?

I meet with my surgeon again on Jan. 25th! I'm really excited to get started again!!

Each insurance company has its own set of requirements. Consider yourself extremely lucky! Your new insurance is great. Since I am disabled, I am on Medicare. Medicare's requirements for medical necessity include: (1) BMI > 35, (2) an associated co-morbidity like diabetes, sleep apnea, hypertension, (3) and a documented history of failed attempts at medical weight management. Yet, Medicare does not specify how many attempts and over what time period. It turned out that I could use documentation from 3 years ago.

Also, each insurance company operates at its own pace. I heard back lightning quick. I applied on Dec. 27th, approved electronically, and was told by my provider today. We even scheduled today.

[Mattymatt 491]

1 hour ago, Hopep4673 said:

not my insurance but i have heard of it being this way... more and more insurances are getting rid of the medically supervised diet requirement. Yes it should make it easier you will likely only need a letter of necessity for your PCP.

However, your surgeon may require more than your insurance like Psych clearance.

Congratulations on your decision and best of luck in your journey.

Insurers are discovering that the medically supervised diet requirement is really superfluous. Since traditional diet/exercise programs haven't worked in the past, the likelihood of them working now is not very high. Recent research shows that only 10% of those that lose weight this way keep it off. I'm one of the 90% that failed. The chances of success of weight loss surgery go up by an order of magnitude to 65%. This could result in statistically significant long term savings for the insurer.

[brendamcfarlane14 7]

I had RNY bypass 6 days ago. My first appointment with the surgeon was Dec 1st. I have a hiatal hernia and reflux that required repair and the only real way to guarantee not having further problems with the reflux was the RNY. My insurance approved as soon as all pre-op lab work was done (took about 12 days since we went on vacation the day after my first surgeon visit.)

My surgery was not submitted as a weight loss surgery though - it was submitted as a hernia repair using RNY.

[jmangino 6]

My insurance wanted the 6 month diet, but they accepted a recommendation from my surgeon to skip it (he said the same thing mattymatt said about the dieting). It still took about 3 months for me to get all the appointments and tests done just because of scheduling issues though, and then I had to push the surgery date back a few weeks into february bc of work. That's still not much time though, from the other experiences I've seen/heard of, so I think I'm pretty lucky

[Tasia29 9]

not my insurance but i have heard of it being this way... more and more insurances are getting rid of the medically supervised diet requirement. Yes it should make it easier you will likely only need a letter of necessity for your PCP.
However, your surgeon may require more than your insurance like Psych clearance.
Congratulations on your decision and best of luck in your journey.

That's good to hear. As far as my surgeon his assistant already told me that my previous psych clearance is still good and wouldn't need to do it again. Before I decided not to have the surgery I already did all requirements my surgeon had and only had one more lifestyle class to attend. I had a surgery date depending on insurance approval. Boy I'm kicking myself in the butt for not doing this month's ago. Hopefully I'll be approved with no trouble. Good luck on your weight loss journey [emoji4]

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[Tasia29 9]

Thank you everyone for your reply. Good luck to you all on your weight loss journey!! [emoji4]

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