Jump to content
×
Are you looking for the BariatricPal Store? Go now!

Molina denied gastric sleeve



Recommended Posts

My BMI is 47.3 but I don't have diabetes or other health problems does anyone know what I can do next to get approved ? If I don't get surgery and lose weight health problems could follow just don't understand why they wouldn't want to prevent them paying more money in long run . I am desperate ?? !!!

Share this post


Link to post
Share on other sites

It's generally true that the costs for WLS are significantly less than later associated medical costs without WLS. Insurance companies do not expect to be paying your later medical costs. Thus, paying for WLS now is cash out of their pocket and some other insurance company (or entity) will reap the benefits of the lower costs later. "No" is nearly always the best answer for their bottom line now.

Some insurance companies won't cover WLS. There is virtually no way you can get them to cover it.

Some insurance companies cover WLS but make it very difficult (or have a reputation for making it difficult). For these there are several things you can do to improve your chances of approval:

1) Review the requirements and be sure you have documented compliance. Demonstrated morbid obesity (mine was 5 years), a medically supervised diet (mine was 6 months within the last 2 years). They have a list, you need the list and check off every item;

2) Comorbidities: If folks have a lower BMI sometimes insurance requires comorbidities. So, oddly, completely healthy is bad. Thinking outside the box can help: Back pain, knee pain, sleep Apnea, GERD, hernia, type 2 diabetic, anything even remotely connected;

3) If you get denied, find out EXACTLY why. It could be they don't cover it at all, or that a piece of documentation was left out. Find out from the insurance company;

4) Call the insurance company and ask for their help. While the insurance company may be loathe to cover WLS, the customer support folks get rated on how well you think they have helped you. I've never encountered an Insurance customer support person that wasn't helpful. If you get an agent that isn't helpful, call back and talk to a different one.

5) You are your best advocate. If you don't do the work it's unlikely anyone else will do it for you. People have changed where they work to get insurance that covers WLS. Figure out how far you will go to get it then don't stop.

Good luck,

Tek

Edited by The Greater Fool

Share this post


Link to post
Share on other sites

I had one of those companies that did not cover WLS regardless of the circumstances. Luckily, we had a choice of insurance companies with my former employer, so I switched to one that covered it. But like Greater Fool said, if yours claims they cover it but is just making things difficult for people to get it, then follow his suggestions../

Share this post


Link to post
Share on other sites

The insurance company must tell you in writing why they are denying coverage for the WLS. Your BMI is high enough, so there must be another reason. You can (and should) challenge denials, up to and including "peer to peer" reviews during which your surgeon talks to a high level person at the insurance company. Every appeal takes it up a notch to someone with more knowledge and authority. You have alternatives if appeals fail. One is to complain to your state's Commissioner of Insurance.

Share this post


Link to post
Share on other sites

My BMI is 47.3 but I don't have diabetes or other health problems does anyone know what I can do next to get approved ? If I don't get surgery and lose weight health problems could follow just don't understand why they wouldn't want to prevent them paying more money in long run . I am desperate ?? !!!

Well, if they're saying you need a comorbiditie, like diabetes, then unfortunately, that's what blood tests would have to show to be approved. That's what happened to me. I have Amerigroup, but I heard Molina is similar.. I was denied bc I didn't have that or debilitating joint issues (something to that effect)...I was pre diabetic when I submitted my paperwork. I retested and I found out I was in fact diabetic. I was approved quickly thereafter.

Sent from my SM-G975U using BariatricPal mobile app

Share this post


Link to post
Share on other sites

Create an account or sign in to comment

You need to be a member in order to leave a comment

Create an account

Sign up for a new account in our community. It's easy!

Register a new account

Sign in

Already have an account? Sign in here.

Sign In Now

  • Trending Products

  • Trending Topics

  • Recent Status Updates

    • Debbie Nichols

      No plans for surgery 
      · 0 replies
      1. This update has no replies.
    • amazingmimi

      I feel like I've finally gotten past the biggest hurdle. Surgery date is September 6th, the day after Labor Day, and yesterday I got my insurance approval letter. I've followed everything they've told me to do, and I've even lost 30 lbs on my own since hubby had to change his diet for diabetes. No worries now about having to do 4 weeks of the liver shrinking diet instead of 2. On my initial visit, if I had gained just 5lbs I would have had to do 4 weeks. It's getting closer. Just 2 more months to wait.
      · 1 reply
      1. NmMd

        Although the prep work took energy, I found the biggest hurdle was post-operative. The first 48 hrs were extremely uncomfortable. I did an overnight and trying to down the liquids, Tylenol, and especially the barium was rough. Thankfully though, I got away with only having to have 1 belly injection after surgery. Needless are not my thing.

    • Grace1234

      I am brand new to this my surgery is tentative for July 27 depending on insurance and I'll be have the Gastric Sleeve.
      · 0 replies
      1. This update has no replies.
    • Pepper1

      I am looking for people to connect with that are 4-5 years out. Many of the support sights I go to are all newbies. And while I enjoyed that when i first had my surgery and found it useful, I am looking to exchange ideas with folks that are out a few years. I am slowly gaining weight back and losing my excitement. I don't want that!
      · 1 reply
      1. SleeverSk

        Maybe post in the forums. It's a more active areaI have noticed no one replies to status updates

    • SuziDavis

      I have a surgery date! I am getting sleeved on 8/17/2022!
      · 0 replies
      1. This update has no replies.
  • Recent Topics

  • Hot Products

  • Sign Up For
    Our Newsletter

    Follow us for the latest news
    and special product offers!
  • Together, we have lost...
      lbs

    PatchAid Vitamin Patches

    ×