Insurance Question

[SpecialK92 10]

Hey All!

I'm a newbie here, but I've finally decided to start the process and get information about VSG. I feel mentally ready for it and that it's time, as I've been going round and round with the decision for years.

I go back to my new PCP on 3/10 of this month to discuss it more and get bloodwork. I gave her a head's up at my initial consult that this was something I wanted, and she said let's see if you are a candidate at your next appointment. I already made my appointment with the weight loss center for the information center on 3/25. They advised they do not need a referral from my PCP, but to have my most recent labs sent over. When I called the weight loss center, I was advised that after the information session, you will be contacted within a week for the actual consult with the surgeon. I've been doing a ton of research so far, and I see a lot of folks have a 6-12 month supervised diet mandate with the insurance. After contacting my insurance company, they sent me the policy and advised that they have lifted their 6 month restriction. My policy states the following is needed for approval.

• BMI 40 and over or BMI of 35-39 with co-morbidity.
• Individuals should have documented to respond to conservative measures for weight reduction prior to the consideration of bariatric surgery and these attempts should be reviewed by the practitioner prior to seeking approval for the surgical procedure. HOWEVER, following that statement, it says "As a Result, some centers require active participation in a formal weight reduction program that includes frequent documentation of weight, dietary regimen, and exercise. However there is a lack of evidence on the optimal timing, intensity and duration of non-surgical attempts at weight loss, and whether a medical weight loss program immediately preceding surgery improves outcomes." HELP- what does this mean?
• Psych consult

I'm pretty clear on the other first and last requirement, but the 2nd one has me spinning my wheels slightly. When I called my insurance to ask for clarification, I was advised that a letter of support from my PCP would likely suffice. My only hesitancy is that I just started with a new PCP, and I'm wondering if she will approve me off my BMI alone, or want to try conservative measures first since I am new patient there. If she doesn't provide letter of support, will the nutrition classes that the surgeon will inevitable require satisfy the letter requirement, can he be the one that writes it or does this text indicate that it needs to come from my PCP? I plan on calling the center during their business hours to ask if they've encountered this insurance wise tomorrow, as they were closed today.

Any one run into this issue with their insurance policy? Any insight or perspective offered would be awesome.

[Cia2020 77]

My insurances have language that I just had to follow the facility/program's "procedure" to be approved for surgery, but they don't require any specific time frame either. So if you go to a clinic that requires 3 monthly visits, 5% body weight loss, nutritionist classes, etc... then you will have that long of a wait. It depends on your clinic and your weight, comorbidities, tests you need/already have done, etc... Mine was more just how long it took me to get my new primary insurance to kick in as well as see 1) the nurse 2) a psychologist 3) the nutritionist. They recommend 5% body weight loss, but mostly just don't want to see any weight gain. Mine went like this:

Late Oct. 2019: I sent in my interest paperwork online to clinic
Nov. 20th: First nurse visit
Nov. 21st: Labs drawn at my GP
Dec. 4th: Psychologist
Dec. 11th: Second nurse visit
Jan. 2nd: Nutritionist

They sent in the referral to the surgeon.

Jan. 29th: Surgical consult, scheduled endoscopy and surgery!
Mar. 2: Endoscopy (for atypical GERD)
Mar. 16th: 2 hour group nutrition class
Mar. 19th: Last pre-op appt. with surgical staff
Mar. 26th: Surgery day (the day I wanted anyway so I could use Spring Break to avoid using too much sick leave)

[SpecialK92 10]

Thanks so much for the info!

[catwoman7 11,273]

sounds like typical insurance policy language - that is, a head scratcher. I'd be tempted to just call the insurance company and ask them what the heck that means. (I wonder if the insurance rep who answers the phone will even know? Sheesh. They may have to put you through to a manager for that!)

[SpecialK92 10]

Yeah, when I called the first time, the rep told me a letter of support from my PCP should suffice, but I likely will call again and ask to speak to a manager for further clarification, I want to be well informed early!

[Cia2020 77]

Question everything and write it down! My weight loss clinic told me I had to pay for my nutritionist visit and the 2 pre-op/post-OP group nutrition classes out of pocket because "insurances don't cover that" but mine does for both, at 100% actually, saving me from paying $335 cash. Every penny helps!

[SpecialK92 10]

Will do!! I’ll call the insurance again today! I’m hoping I can get by the end of this year, since I’ve already met my deductible for the year. I spoke to the center earlier and since my insurance doesn’t have time restriction, they will do three month supervised diet with clearances. I don’t have an appointment yet for the consult, they will contact me after the session on the 25th I’m told. I’m excited to get the process started!

[FLHappyGirl 171]

I interpret it much like Cia2020 did above. Each WL center will have different requirements and you will need to make sure those align with your insurance. The WL center should have an insurance expert to help you navigate the process. And if for some reason you don't get approval on the first try, don't throw in the towel. Ask why and work to get things resolved.

Oh and if your PCP isn't on board, get a new one. Sounds harsh but I actually had a friend who has a BMI of over 50 and her PCP was horribly misinformed and uneducated about weight loss surgery.

[SpecialK92 10]

Yeah, I called the weight loss center earlier and spoke to their insurance person and she was wonderful. She told me not to stress at all and that they work with my insurance all the time and that it should be no big deal getting it approved. I feel a lot better, thanks everyone!

[Cia2020 77]

Woohoo! 3 months isn't long at all!

Edited March 3, 2020 by Cia2020

[SpecialK92 10]

and yours is right around the corner! how exciting!