need help with approval
(deactivated member)
on 2/1/11 4:40 am - winchester, CA
on 2/1/11 4:40 am - winchester, CA
Hello all,
It seems you are a lively bunch of very educated people, so I'm hoping to get some additional help.
background: I have recently made the decision that gastricy bypass will can help me in my weightloss journey. I have researched and researched and I now know the basic requirements for approval. Called my insurance company and they don't have the specific quidelines listed anymore, as the medical group will, when I go to see them. I went to my PCP (1st time ever seeing him) to get approval and he pulled up a list of requirements that seemed to be worse than any other list I have seen. I have Pacificare insurance and have read mostly good things about getting approved. Turns out the specific medical group was even more specific. I'm still a little confused, but considering changing my PCM to see if I have a better chance at getting approved. Changing PCMs will change me from Primecare medical group to Prime Partners medical group. This might be jibberish to you all, but I'm hoping someone, who has an abundance of experience can shed more light for me. My stats: 5'3" 217 lbs. I'm about 38 BMI with no major comorbidities. Even with 40 BMI, you needed some comorbidities. I was hoping that my minor comorbidities can make me a good candidate. With my old medical group, no way, no how was I going to be approved. I would really like to get this help with the bypass and I'm currently battling the insurance companies.
I appreciate any advice anyone can give me.
Thank you so much!!!
It seems you are a lively bunch of very educated people, so I'm hoping to get some additional help.
background: I have recently made the decision that gastricy bypass will can help me in my weightloss journey. I have researched and researched and I now know the basic requirements for approval. Called my insurance company and they don't have the specific quidelines listed anymore, as the medical group will, when I go to see them. I went to my PCP (1st time ever seeing him) to get approval and he pulled up a list of requirements that seemed to be worse than any other list I have seen. I have Pacificare insurance and have read mostly good things about getting approved. Turns out the specific medical group was even more specific. I'm still a little confused, but considering changing my PCM to see if I have a better chance at getting approved. Changing PCMs will change me from Primecare medical group to Prime Partners medical group. This might be jibberish to you all, but I'm hoping someone, who has an abundance of experience can shed more light for me. My stats: 5'3" 217 lbs. I'm about 38 BMI with no major comorbidities. Even with 40 BMI, you needed some comorbidities. I was hoping that my minor comorbidities can make me a good candidate. With my old medical group, no way, no how was I going to be approved. I would really like to get this help with the bypass and I'm currently battling the insurance companies.
I appreciate any advice anyone can give me.
Thank you so much!!!
You can go online to pacificare and get the specifics. I have pc and they stated 35 with co-morbids or 40 with no co-morbids. They were very specific about their co-morbids with the 35. I had to take 6 months of education classes. 1 6 month class started in March and held monthly meetings for education on the surgeries themselves, side effects, complications, life after surgery etc and then I had to take 6 months of WEEKLY (at the same time mind you) of classes to do a medically supervised program. I also had to see a doc at the weight loss program and pay copays for that. Then you still have to jump through psych clearance, health screens and whatnot...
From what I recall it's not the medical group that sets the standards, it's the insurance company itself. Whoever is saying they don't have "specifics"...must be their first day or something because when I called the number on my PC card they went straight to patient benefits on their computer and told me exactly what I needed to do.
Best of luck to you
Binda
From what I recall it's not the medical group that sets the standards, it's the insurance company itself. Whoever is saying they don't have "specifics"...must be their first day or something because when I called the number on my PC card they went straight to patient benefits on their computer and told me exactly what I needed to do.
Best of luck to you
Binda
(deactivated member)
on 2/6/11 1:46 am - winchester, CA
on 2/6/11 1:46 am - winchester, CA
thanks Binda,
From everything I read online, it seems that Pacificare sets the standards, but this medical group I went to had different guidelines. so confusing! Then, I call Pacificare again and they said they don't have the guidelines in their handbook anymore. So, I'm wondering if the power is actually in the medical groups hands now. Pacificare seems confused as well. I'm gonna try and call a new medical group and if the requirements are not so crazy, then I can possibly switch. Anyway, thanks for your help. wish me luck :)
From everything I read online, it seems that Pacificare sets the standards, but this medical group I went to had different guidelines. so confusing! Then, I call Pacificare again and they said they don't have the guidelines in their handbook anymore. So, I'm wondering if the power is actually in the medical groups hands now. Pacificare seems confused as well. I'm gonna try and call a new medical group and if the requirements are not so crazy, then I can possibly switch. Anyway, thanks for your help. wish me luck :)