Insurance questions/starting the process

I am new to the forum and have a few questions that I hope can be answered. I have Optimum Choice and have checked with them about this procedure and have signed up for Weigh****chers. I understand about the 6 months but when should I get my first consultation??? I understand after you see him, you dont see the surgeon until the day of surgery. Now, back to the insurance, if I lose weight then I dont qualify for the surgery. What is the point then???? I can lose a pound here and there but it never stays off and then I just gain more. Why am I doing this program????? Also, my BMI is 36.7 but I have 5 comorbidities, does the fact that my BMI isnt over 40 end up a bad thing to get approved even with the other medical issues???? Is all this hoop jumping needed to just end up approved???? I mean we know Maryland has that law so what is the point of all of this?????? How can they deny you??? Whew! I vented and got all of the questions out.......................for now. Jen

Hi Jen, You should probably start 'shopping' for a surgeon now and find the one you want to go with.  Attend the seminars and find out what they expect from you.   I believe that once you start the process even if you are on a supervised weight loss program the weight/BMI at the beginning is what counts.   There are other tests and procedures that you will need to have done, so if you do those during the 6 months it's likely that you may be scheduled quickly after the 6 months is up. If you have Optimum Choice does that mean that you will need a referral from your PCP?   If so, is your PCP on board with this and supportive?   Even if you don't need a referral, with your BMI not over 40 you will need a letter of medical necessity. Maryland has the 'law' but there are still loopholes and the insurance companies make the most of them with the tests/supervised programs etc probably hoping that we will give up. Best wishes as your WLS journey continues. Hugs, Mo

Hi Mo, My PCP has left the practice so we are waiting for another to come and take her place. I did however call the MD and have placed that Weigh****chers was what I was going to use and to please note it on my chart. This way I have something for the new PCP to see.  I may have to go to the office for a weigh in but plan to use the weigh****chers weight and BMI and submit the record when the time is right. I think I found a surgeon and I plan to see him in January. I will then be about complete the 6 months and they state the wait time for surgery is about a month. Pre op testing is in my PCP office which I have done in the past for my knee surgery so that should not be an issue. I think there is a psych review and nutritionist and I hope if all goes well to have surgery in MArch or April. I will need to find out about the ewight issue with the insurance. I wish I knew when they decide whether it is a go or not. Do they wait until I lose weight then say no as I think they require the program first. Anyway, still so many questions. Jen

Hi Jen, It sounds like you have your plan pretty well together!  When I had my WLS in 2004 my surgeon's office handled everything with the insurance and I didn't have to do any 3 or 6 month plan prior to submission so I am really unfamiliar with how it all works now. My surgeon's office also coordinated all the tests I needed to have.  I was traveling from the Annapolis area to Salisbury so they arranged things in Salisbury. I would think that your BMI at the time of referral (which would be now) before you start the 6 month supervised plan would be the BMI of record for your insurance. Best wishes as your WLS journey continues. Hugs, Mo

I am also starting this process and have the same insurance that you do.  I'm still trying to pick a surgeon as I meet with my PCP tomorrow for the first time about surgery.  I've done WW in the past and it didn't work for me, so I'm not crazy about spending out money weekly again for it.  I'm hoping my doc will let me do a supervised documented diet through them where I just go in and weigh in each month.  I'm hoping that qualifies...

Hi there! I called the insurance and they did say that it had to be 6 month of either 1 diet plan or 2-3 month plans. I have done WW before and but am going to do it again for 3 months. I cant remember if I had the option of going tothe MD office for weigh ins. I do think they did make a big point about it being supervised so I may go to the MD for the last 3 months. I called the surgeons office to see what the protocol was and when I get close to the end of the 6 months they said to make the appointment to see the surgeon.  Jennifer

Hello~

New to this forum as well,  I started my WLS journey almost 4 months ago. After almost 2 decades of being over weight I finally made the decision to go for it :~) I was referred, by a friend and former patient, to Dr. Joseph Afram in Washington. My experiences with him and staff thus far have been extremely pleasant and helpful.  Now to the insurance info ........ I too have Optimum Choice, yes they make you go through a supervised, Dr. Afram in my case, weight check in / evaluation before they will approve you. I don't think it's neccessary for you to join any type of program ie: weigh****chers, jenny or any other. What the insurance wants to know is that you have tried to lose weight before and have been either successful or not. The key is.......no matter what program you do, the weight comes back + more over a period of time. I also think that if they put a clause, the 6 months, some people will be turned off and not want to pursue the WLS.  My doctor and his staff do all the leg work for me. After filling out all my paperwork and listing the multiple diet programs and weight loses/gains I've had, my insurance; Opt. Choice requested a 6 month surpervised diet plan.  Now you can either go through your primary Dr. or you can go to Dr. A. My choice was Dr. A because my primary Dr. is a stickler for doing things the proper way ( diet and exercise ) when I know this option has failed and failed again.  I'm in Dr. A's office every month to get my weight checked and he does the rest. This past month to my surprise I've already got my psy evaluation and nutrition appointment scheduled. The next step is for insurance to approve the surgery, which the staff says happens fairly quick ( 1 wk )  with Opt Choice. I'm looking at surgery for the end of August ;~)) no more double chin !! HE HE  LEt me know if this helps, if you can just stick it out for 4-5 months and go through the weight checks I think it will be smooth sailing with the insurance . Best of Luck! " When you are up to nothing, god is up to something, believe the impossible. "

Hi! I did the WW AGAIN because of ease but I will only do 3 months then I too will go the PCP office for weigh ins. The surgeons office told me to talk to the PCP and make sure of the letter that is written that it is very clear of past attempts as this will be submitted to the insurance. My thinking is that by the time the 6 months is up I am hoping to already have the referral from the PCP to the surgeon, my letter written, the psych exam done and on the way to the nutritionist. My BMI is around 37 but I have 5 comorbidities. I hope I still get approved as I worry that since mine isnt over 40 that could be a reason for denial.  As for your double chin..........................I can beat that. :) I cant wait to not look 35 months pregnant. ;) Keep in touch Jennifer