What were your insurance company requirements for approval?

[Jodi_620 37]

I will keep you in my prayers Melissa. I know what you are going through, I was on pins and needles while I was waiting to hear back from them.

[sil 0]

hi my insurance is bluecare family plan of ct. the insurance require 6 months nut classes tomorrow is my second app, my surgery is to be at yale newhaven hospital by dr. robert bell ihear he,s great my pcp recomended him.

[CCluvs2scuba 0]

Hi Everyone!

My first appointment with the nutritionist, doctor and psych eval is on May 27th. I have Blue Cross PPO and I am wondering if you have to have any documentation from your PCP. I am going to a Center of Excellence and when I talked to the insurance company they said that they would pay 100% of a COE, but I am a little worried because I had to fire my previous PCP due to the fact that he almost killed my son when he did not diagnose his Type 1 Diabetes (his bc was 829 and he had all the signs!) My new PCP doesn't believe in lap-band. I have only been going to him for a year. I hope the insurance company does not need a letter from him. Also, my BMI is 39.1 right now. I know that is under the usual 40, but I do have a couple of the co-morbidities.

[BING9910 0]

:tt2:Hey!

I don't think you will need anything from your PCP, or at least I didn't. However, I have UHC. I got a letter anyway, but didn't have to have it. I scheduled an appointment withc the surgeon I selected and after all of my evaluations, he decided if I was eligible for the surgery.

Hope this helps. Best of luck to you!

Melissa

[new_jewel 1]

When i chose my dr, the very first visit i went to, i asked her what she thought of bariatric surgery...her answer would make me decide if i was ever going back to her...i had researched wls for 8 yrs and i knew that it was very important for your pcp to back you...its hard enough jumping through all the hoops the insurance company makes you..i couldnt imagine if my dr was against it. I am lucky enough to have blue cross blue shield so i didnt have to have anything from my pcp i just chose a bariatric center who was contracted with my insurance, went to my intl consult, had a psych eval, pre-op screening, then was banded a month later...i think it should be that way will all insurance companies...i wish you the best of luck with getting approved

[Peacedove 0]

CC.... Blue Shield varies DRASTICALLY from state to state. I'm told that Alabama requires 6 months of doc supervised dieting, as does GA. But I have BS of CA and although I live in GA, they give me all the same benefits as a policy holder in CA. So, they approved me in 4 days without the 6 month dieting! It was crazy unbelievable. I got evaluations from the shrink, the dietician, and the surgeon gave the medical and surgical evaluation....after I'd only seen him once. I also happened to have a letter from my orthopedic surgeon in favor. They approved me with no questions asked. As for getting your Primary Care's approval. NOT necessary with a PPO. Just make sure you pick a bariatric surgeon that is in your PPO network. I have to drive 3 hours to get to mine. But BS is also saying they will reimburse travel expenses because of this.

[🅺🅸🅼🅼🅸🅴🅺 296]

CC.... Blue Shield varies DRASTICALLY from state to state. I'm told that Alabama requires 6 months of doc supervised dieting, as does GA. But I have BS of CA and although I live in GA, they give me all the same benefits as a policy holder in CA. So, they approved me in 4 days without the 6 month dieting! It was crazy unbelievable. I got evaluations from the shrink, the dietician, and the surgeon gave the medical and surgical evaluation....after I'd only seen him once. I also happened to have a letter from my orthopedic surgeon in favor. They approved me with no questions asked. As for getting your Primary Care's approval. NOT necessary with a PPO. Just make sure you pick a bariatric surgeon that is in your PPO network. I have to drive 3 hours to get to mine. But BS is also saying they will reimburse travel expenses because of this.

Wow, how did you get BS of CA when you live in GA? lol :cursing:

[Char_in_Md 0]

I have carefirst bluecross/blue shield PPO...not sure what they require yet, my primary doctor just told me about this surgery today, due to having sleep apnea....guess I am about to find out after the holiday...

[Peacedove 0]

I have BS of CA because the company I work for is based in southern CA. Otherwise, I'd probably be in the same boat. Several gals at the home office have had breast reduction surgery...basically, they wanted a lift after loosing a little weight, and the insurance also paid for that! I am going to do that next, if I don't loose all my boobs with the weight loss. I still need to find out if they will cover the fills, and follow ups. I don't see why they wouldn't. Good luck to you all and I hope your insurance is a good to you as mine was!

[AliNSanDiego 1]

I have UHC PPO Choice Plus. This is becoming a real game with what is covered, what is not & who is in network and out of network. I can't seem to get any solid answers and just keep hitting a WALL every time I try to schedule all this stuff required to even SUBMIT to insurance for approval. SIGH............

The insurance company tells me they will only cover if...

40+BMI OR 100 pounds overweight

OR

35+BMI + co-morbidities

The surgeon I went to see says...

40+BMI 100 pounds overweight

OR

35 w/ Co-Morbidities

PLUS...

Psych evaluation/clearance ($350 out of pocket - psychologist referral surgeon gave me not covered by insurance :confused2:)

Bariatric Dietician ($100 out of pocket - not covered by insurance :confused2:)

Bariatric group Diet Class ($10 out of pocket)

Group Seminar

I am going to be one pissed off person if I put out nearly $500 and then the insurance says NO, SORRY...not covering you.

[Froggi 4]

My insurance requires 6 month supervised diet and psych evaluation. I start month 2 June 4th!!

[boxergirl301 0]

Kimmie,

It's usually not as easy as just who is your insurance company. Here are some things you need to find out:

#1. Is your insurance plan self-funded or fully-insured? You can find this out by calling your HR dept, going online and reading your benefits materials, or by calling your insurance company. Often times, larger employers offer both self-funded and full-insured plans to their employees (so an Aetna plan might be self-funded and a BCBS plan might be fully-insured).

#2. If your plan is fully-insured, go online to your insurance company's website and go into the 'provider' section. You want to look for something that is similar or close to 'medical policy'. You should be able to access this section without having a provider login. You will then want to find the medical policy that pertains to the lap band (sometimes its listed under just surgery). Insurance company's medical policies list out not only what they will cover, but what the requirements are to have that something covered. So it will tell you what your BMI needs to be, if you need co-morbidities, if nutritional counseling is required, etc. If you can't find this, you can call your insurance company and they should be able to either mail you or tell you where the medical policy is as it is public information.

If your plan is fully-insured and your request is denied, you should be able to appeal (depending on the language in your plan documents) 2-3 times. However, appeals generally dont get overturned as appeals are only sent to other insurance company staff to review each time.

Based on medical policy alone, UHC is generally your best bet - their basic requirement is that you have a BMI of 40 or greater or 35 with 2 co-morbidities. BCBS plans and Aetna generally require nutritional counseling, a stated history of morbid obesity, a 6 months doctors supervised diet, etc.

#3. If your plan is self-funded you have more options. Self-funded plans (in simple terms) are plans in which your employer actually creates the plan and the requirements and then hires an insurance company to administer the plan by paying claims - even though all the money for all claims comes from your employer. This means your employer has flexibility in what is and is not covered.

So if your plan is self-funded, call your insurance company and find out the medical policy still. Most self-funded plans still use insurance company medical policy to make decisions cuz its easier.

However, you will then need to call either your HR rep, your insurance company or participant advocacy (if you have one - a lot of fortune 500 companies are getting advocacy depts) and find out if your employer has any additional restrictions on the procedure.

For example, my last employer (with the second largest benefits consulting firm in the world), I had UHC EPO. UHC's medi5cal policy stated that they only require a BMI of 40. However, my employer said, in addition we require a 5 year history of morbid obesity and a 6 month doctor's supervised diet. My employer's requirements overwrote the insurance companies medical policy since my employer was footing the bill.

Now, here's the good news with those self-funded plans. If your request is denied, generally you have 2-3 appeals left. The first 1-2 appeals would be to the insurance company (no help), but generally, your last appeal would be sent directly to the administrator of the plan (your employer!). This is your chance to state your case about how a $50k surgery (or whatever it is) will save them $75k in future claims. Most larger employers have a benefits committee that meets once a month (made up of past and future HR employees and executives) and they make final decisions based on the appeal you wrote. If your employer feels sorry for you, or maybe they have extra money to throw around:lol: they can override the insurance company decision and you can have the procedure.

I know this was long, but I have worked in this industry for over 12 years and even I had issues getting my procedure covered (thank God for the LARGEST benefits consulting firm in the world - #2 sucks).

[Peacedove 0]

I am SO mad!!!! You would not believe what someone at my insurance company emailed me with!!!! I spent ALL day yesterday driving 6 hours to and from my surgeons office and the hospital to do pre op testing and when I got home last night, BS of CA sent me an email that stated I had not been approved for this procedure!!!! I was so mad that I called and got some young gal who didn't know anything and couldn't find my approval. She told me to call again today. Today I called and got hold of a woman that took 10 minutes to find it, but DID find it. She then told me that she was going to find the person that sent me the email and call them to straighten them out. I was asking them about travel reimbursements and instead they sent me into this emotional whirlwind. I'm so mad.:wink2:

[GramaLisa 0]

Hi, my husband works for MCLB, the Marine Base in Barstow, CA. We get BCBS FED PPO through his work. So far in just a week and a half I have gone to the initial seminar, saw the surgeon directly after that, got a call from the insurance co-ordinator, got a call from the psychologist, and then a call from a nutritionist. They have told me that this is all I need to do before they send in a packet to the insurance company. My BMI is 37 but I have several qualifying co-morbidities, arthritis, stress incontinence, GERD, degenerative disk disease, and hip pain. They have told me that it may take up to 45 days for the ins. company to give the OK but that they should give me the approval. The nut. also said that with BCBS I should not have to go through the 6 months of supervised dieting that I have read about. They seem to think that our insurance is pretty good at getting approval. Now I am just waiting for approval and whatever else they will require of me before surgery. Now I just need to work on quitting smoking, cutting out soda pop and excess calories, and getting more exercise. This morning instead of stuffing my face and smoking too much I got out and mowed the lawn and weeded and raked.

[cowgrrl 0]

I have UHC PPO & was approved ridiculously quickly. I had started the process in January thinking that it would take a long time but I was approved without even a drs appointment & if I hadn't had a few conflicts they would have been able to do the surgery in mid-March.

I have a BMI of under 40 but I have other issues.