How does HMSA Cover the Sugery?

I havent gone to the doctors ever since high school. I decided to go due to not having my period for 6 or 7 years. The doctors told me that It pretty much looks like i have PCOS. However, due to procedure they need to eliminate all other conditions also.  but when im diagnosed, he is going to refer me to a physical trainer, dietician, and sugeon to get WLS. My stats are im labed pre-diabetic, no menstal periods, low good cholestrol levels, im 5'6" and 298 lbs. I have the dark patches on my neck. How do i know if HMSA will approve my sugery, what is the reason they approved yours? I just dont want to get my hopes high for something that might not even come to pass. Please advise.

Thank you Jessica

Aloha Jessica-

Sorry your post has gone unanswered here, but it's probably because none of us know what your policy will cover since we don't know what policy you have. The best thing you can do is start doing your "homework."

You'll need to talk with your insurance people and find out the answers to all your questions... find out which surgeries they will or will not cover... find out if there require there to be co-morbidities or other prerequisites before they will cover WLS. You should have some kind of booklet or you can probably check online at your insurance website.

As far as "getting my hopes high for something that might not even come to pass".... some of us have done that and been refused and have gone the "self-pay" route. For me, having the procedure and surgeon I wanted was important to me. My insurance would not cover an out-of-state surgery/surgeon, so I had to dig deep to get what I wanted, but I don't regret a single moment.

I hope you find the answers you need to continue your journey. Know that we're here for you if you need us, too!

((hugs))

Hi Jessica,

I had HMSA approve my surgery.  I did not have any comorbidities except that my BMI was 50.  This is the Criteria ans Guidelines from HMSA.  Again the process is different if you have HMO or PPO.  With HMO you have to have your primary care doctor to refer you.  With PPO you can go directly to the Surgeon. (most cases)

Also, you need to check with your company's insurance to see if they cover Bariatric Surgery.


Hope this helps!!  If you need any specific info on what I went through, feel free to message me :)

Good Luck, Viki

II.  Criteria/Guidelines
A.  Surgery for morbid obesity will be covered for members when the following criteria are met:

1.   The patient is morbidly obese, defined as either of the following:

 a.   Persistent and uncontrollable weight gain that constitutes a present or potential threat to life, characterized by:

 i.    Weight that is at least 100 pounds over, or twice the ideal weight specified in the current Metropolitan Life Insurance Table (Click for Metropolitan Life Tables), or

ii.   A BMI greater than 40 kg/m²; or

 b.   BMI of between 35 and 40 kg/m² with one of the following high-risk comorbidities:

 i.    Severe sleep apnea (defined as repeated hypoxia < 80% on sleep study); or documented pulmonary hypertension on echocardiogram or right heart catheterization; or sleep apnea induced right heart failure requiring hospitalization)
ii.   Pickwickian syndrome

iii.  Obesity-related cardiomyopathy (defined as global cardiomyopathy with estimated ejection fraction < 40 percent)

iv.  Severe diabetes mellitus with documentation of severe insulin resistance not adequately controlled (Hb A1c > 8.0 percent) on insulin sensitizing agents and  80 units of insulin a day







 

Thank you for replying...it's such a big relief in my journey to surgery. As for surgery, I have HMSA HMO. And As far as paying out of your pocket, it will be a big investment. But worth it. i really need to conquer my life and im very excited to do so!!!! Thank You!!!!!

I have HMSA also.  Everything was covered but 20% of the hospital stay and the surgeon fee.  Dr. Fowlers surgeon fee was $600.00 and that covers all pre and post op.  PT Trainer and nut.  You might have to pay a little for the pyche eval.  I had to pay $16.00, 

When I talked to a HMSA rep back in July I wasn't able to see DR. C because they wouldn't cover off island surgery.  I noticed that some recent DR.C patients been having their surgeries covered you might want to look into that. 

Call HMSA to see what there covererage is for your policy.  Be happy with HMSA they are very fast.

Aloha,
Asia