Priority Health and the VSG

Has anyone had a problem getting "sleeve" surgery approved by PH? Has anyone been successful?   Hoping to have VSG in April with Dr. Foote at MMPC and he says it could go either way.  I have arthritis and take ibuprofen on a regular basis and may need prescription drugs at some point.  This is good because you can generally take these yet when you have the sleeve.

I also would like some info on Priority Health....a friend has been denied 2 times now. His BMI is 47 and he has at least 1 co-mobidity. He says that with PH if your BMI is over 45 you are automatically accepted.  Anyone have any insight.

I have priority health and my bmi was 42 and was approved for rny with no problem but I had already completed the required 6 month supervised diet have you done that?

I have Hap and had surgery already..but a friend at work has been denied twice now....and get this...his BMI is like 47-49.....but he definitely qualifies...but they sent back a paer that said he needed the 6 month supervised diet. Perhaps they are playing games and want to see how determined he is...so I told him to file a grievance....

All priority health policies are different, my husband is in the process of trying to get approved for the sleeve and his BMI is only 40.5 but he already completed the 6 month diet. As far as I know with my policy you must complete the diet no matter what your BMI is.  What would it hurt to take the time for your friend to complete the 6 months as filing a grievance could take a year or longer. My mother in law fought blue care network and won but it took over 2 years.

My BMI is 39 and I have appealed to PH 3 times. The final ruling is that I still have to go through the medically supervised diet, then they will allow me a surgical consult. The paper I have listing the policy says that you don't need the diet if your BMI is over 45. I actually had someone from PH tell me if I could manage to gain 30 more lb. and get to 260, I would be approved for the surgery, no problem. I can't believe they said that. The policy reads: "6 months medical management does not apply if BMI >45 and ANY of the following is present: *significant pulmonary disease *significant cardiac disease *hypertension requiring triple therapy (personal note--remember that diazyde is a combo drug, thus counting as two) *diabetes with A1C> 7.0 and either triple therapy or insulin. OR if BMI is >55, no comorbidities are required. and then it goes on to list conditions that would make one ineligible such as pregnancy, severe psychopathology, cancer, uremia, liver failure with survival of less than one year, substance abuse or tobacco use. Hope that helps. Penney