Insurance Requirements — Have any of you ever bypassed or shortened the wait period?

[mil_unloaded 80]

Hi there.

I have a significant hiatal hernia, it causes a lot of pain and discomfort any time that I eat. I had an endoscopy to rule out infection or strangulation of the stomach. Anyway, the findings were that it’s likely that I have nerve damage in my hiatal hernia area and diaphragm.

I have a telemedicine appointment with my bariatric surgeon on Monday, it’s my first consultation. My insurance “requires” 6 months of nutrition education before they will sign off on the surgery. I’m not asking to do it in 2 weeks, or even a month. I’m just curious if anyone out there has been able to petition their insurance with the help of a physician to shorten that time frame. I’m aware that I’ll need to do the work before the surgery, but my concern is being in this pain for 6 months. I can do maybe 2-3 months.

Anyway, if you have been able to do this, or know of someone that has, can you just give me some insight? I’m not familiar with how insurances work.

[NurseJaci13 11]

1 hour ago, mil_unloaded said:

Hi there.

I have a significant hiatal hernia, it causes a lot of pain and discomfort any time that I eat. I had an endoscopy to rule out infection or strangulation of the stomach. Anyway, the findings were that it’s likely that I have nerve damage in my hiatal hernia area and diaphragm.

I have a telemedicine appointment with my bariatric surgeon on Monday, it’s my first consultation. My insurance “requires” 6 months of nutrition education before they will sign off on the surgery. I’m not asking to do it in 2 weeks, or even a month. I’m just curious if anyone out there has been able to petition their insurance with the help of a physician to shorten that time frame. I’m aware that I’ll need to do the work before the surgery, but my concern is being in this pain for 6 months. I can do maybe 2-3 months.

Anyway, if you have been able to do this, or know of someone that has, can you just give me some insight? I’m not familiar with how insurances work.

Double-check if it is 6 months or 6 diet visits in different months. It may seem like splitting hairs, BUT...it can save a lot of time. For example, my first diet visit is tomorrow and my last visit is scheduled for the first week in November...a little over 4 months start to finish. It's a small loophole that surgeons/billing departments know about.

[jenlp88 4]

I was fortunate enough to skip all of that. I had a zoom consultation then my surgery was booked for a week and a half later. I had to only get blood work done. But I was self pay so I didn’t have to meet insurance set requirements. I also received almost half off the procedure due to covid! I know it must be such a pain to weight and have to jump through all of these hoops! Good luck.

[ms.sss 14,711]

5 hours ago, mil_unloaded said:

Hi there.

I have a significant hiatal hernia, it causes a lot of pain and discomfort any time that I eat. I had an endoscopy to rule out infection or strangulation of the stomach. Anyway, the findings were that it’s likely that I have nerve damage in my hiatal hernia area and diaphragm.

I have a telemedicine appointment with my bariatric surgeon on Monday, it’s my first consultation. My insurance “requires” 6 months of nutrition education before they will sign off on the surgery. I’m not asking to do it in 2 weeks, or even a month. I’m just curious if anyone out there has been able to petition their insurance with the help of a physician to shorten that time frame. I’m aware that I’ll need to do the work before the surgery, but my concern is being in this pain for 6 months. I can do maybe 2-3 months.

Anyway, if you have been able to do this, or know of someone that has, can you just give me some insight? I’m not familiar with how insurances work.

Not sure if you want to go this route but its an option: Insurance should cover the hernia repair without any waiting period. You can get the hernia repair now (or sooner), to at least address the pain you are in, and then complete the 6 months and get the WLS.

[mil_unloaded 80]

Just now, ms.sss said:

Not sure if you want to go this route but its an option: Insurance should cover the hernia repair without any waiting period. You can get the hernia repair now (or sooner), to at least address the pain you are in, and then complete the 6 months and get the WLS.

My gastroenterologist said that the only way they would do the hiatal hernia repair at my current weight is to also do my gastric bypass at the same time. Otherwise I would have to lose 150+ pounds before they would even do the repair. That could take 3+ years without the surgery...

[ms.sss 14,711]

6 minutes ago, mil_unloaded said:

My gastroenterologist said that the only way they would do the hiatal hernia repair at my current weight is to also do my gastric bypass at the same time. Otherwise I would have to lose 150+ pounds before they would even do the repair. That could take 3+ years without the surgery...

Ah, I see.

Have you already put in the request and been denied? I have read of some members who have successfully navigated the appeals process after denials...but not necessarily for this same instance, though. But then again, the appeals process may just take longer than 6 months....

[JessLess 1,163]

I would ask your surgeon's office manager to help with the insurance appeal. They are motivated to help you get it done and know how to code things for approval.

[mil_unloaded 80]

11 hours ago, ms.sss said:

Ah, I see.

Have you already put in the request and been denied? I have read of some members who have successfully navigated the appeals process after denials...but not necessarily for this same instance, though. But then again, the appeals process may just take longer than 6 months....

I haven’t been denied yet. I called my insurance to find out their requirements, and then I called where my gastroenterologist referred me and scheduled my consultation. That’s all I’m at right now.

[mil_unloaded 80]

2 hours ago, JessLess said:

I would ask your surgeon's office manager to help with the insurance appeal. They are motivated to help you get it done and know how to code things for approval.

This is great, thank you for your reply. I’ll be seeing my bariatric surgeon on Monday for my first consultation, so I’m hoping that we can streamline things even just a little bit. I can’t imagine dealing with this pain for 6 months!

[mcfluffington 179]

Good luck! I sympathize with you about a hiatal hernia.

[Luv2cruz 20]

Yep! It’s called Blossom Bariatrics in Vegas. I refused to follow the requirements of my insurance company because they said from the beginning of the process until the time I would have the actual surgery would be a minimum of 12 months. That’s ridiculous! Started searching online and I found Blossom. Had my surgery 7 weeks ago and I am down 39 pounds!

[GG926 41]

On 6/25/2020 at 12:37 PM, mil_unloaded said:

Hi there.

I have a significant hiatal hernia, it causes a lot of pain and discomfort any time that I eat. I had an endoscopy to rule out infection or strangulation of the stomach. Anyway, the findings were that it’s likely that I have nerve damage in my hiatal hernia area and diaphragm.

I have a telemedicine appointment with my bariatric surgeon on Monday, it’s my first consultation. My insurance “requires” 6 months of nutrition education before they will sign off on the surgery. I’m not asking to do it in 2 weeks, or even a month. I’m just curious if anyone out there has been able to petition their insurance with the help of a physician to shorten that time frame. I’m aware that I’ll need to do the work before the surgery, but my concern is being in this pain for 6 months. I can do maybe 2-3 months.

Anyway, if you have been able to do this, or know of someone that has, can you just give me some insight? I’m not familiar with how insurances work.

Hello,

I had a 10cm hiatel hernia so four + inches of my stomach was in my chest cavity. I was approved for surgery in 3 weeks. My insurance was TRICARE.

[RickM 1,747]

It sounds like you have a reasonable chance of succeeding at this, given your situation. Likely what will happen, is that they will apply for approval and be denied due to the six month thing, then they will appeal the decision, and probably have a peer-to-peer review with your surgeon talking to their doctor and then a decision will be made. Likely they will approve it at that point (with some grumbling...) as they would rather pay for just one surgery to do both jobs than pay for the hernia repair now (don't take your gastro's word on this, talk to the surgeon who has to do the job! Surgeons, too, vary widely on their ability to do such jobs,) and then the bypass in a few months.