Medicaid approval
I went through the seminar and all the preliminary appointments for sleeve surgery and actually had surgery scheduled only to be denied because I didn't have an "uncontrolled life endangering event such as uncontrolled high blood pressure or diabetes". Has anyone got approved by Medicaid without an uncontrolled life endangering event? I have a higher risk for breast cancer recurrence because of my weight, lymphodema, reflux, esophagitis, hiatal hernia, chronic fatigue syndrome, a family history of obesity, cancer, high blood pressure and diabetes but no "uncontrolled life endangering event" they said. Please let me know your experience with Medicaid approval.
I have straight Medicaid which I am told is different than the individual type that I think you are describing and they all have different criteria. At least that is what I am finding out. It is very complicated. I am not familiar with diabetes but apparently if they have trouble controlling it with conventional treatment then that could meet the requirement. I think they make it difficult just to weed out the vain people who may want to do if for just personal appearance and not because of health issues. I have appealed my denial and I'm hoping I have enough additional health issues to sway them.
I'm also in the pre-approval process with Michigan Straight Medicaid with the Breast and Cervical Cancer Control Program. I have one year left on my coverage, then I'm out of insurance.
I've met with my surgeon, the nutritionist, the insurance person, had my EKG, echo, stress test, chest xray, the A1C test, and had my psych consult. I've also met with my PCP for their letter of medical necessity and support.
I have HBP, am pre-diabetic, have arthritis in my hips, knees and ankles, venous insufficiency in my legs, urinary incontinence, and rashes in the inguinal folds.
According to Michigan Straight Medicaid, you need at least two co-morbidities (life threatening conditions). While I'm a five year breast cancer survivor, that is not considered life threatening if you're cancer-free. Family history has no play in the approval process. It's all about you.
My BMI is 46, I'm 5'8 and weigh in at 300 pounds.
lsayles, did you need to document a period of medically supervised weight loss?
Sara said that she's not had anyone who has Straight Medicaid rejected, with the exception of one person, and that was because the person didn't complete all of the steps.
I got the opposite reply. I contacted numerous places and most did not accept straight Medicaid because of their criteria and how difficult it was. There were a couple that got approved I guess but it seemed like their medical provider really advocated for them and knew what they were doing. I thinks some places just don't want the hassle when there are so many easy cases to take on. I did not have to do the six month medically supervised weight loss but they did require a lift threatening event. I appealed and sent documentation of the increased risk for breast cancer recurrence, increased issues with Lymphodema, my severe sleep apnea, support letters from three of my doctors, and wrote my own appeal. A couple weeks before my appeal was to be heard I got a call that I had been approved. When I inquired what the decision was based on they just said there was a technical error someone made in filing or documenting my case. I didn't argue or inquire anymore. I was just elated and didn't want to rock the boat. I had my sleeve done on June 17th. I have lost 30 pounds in 10 weeks and 45 since I started the process. I guess you have nothing to lose by fighting for what you want. You just never know how it will turn out. I am 5' 4" tall and started at 248 and now weigh 203. Good Luck.
Fantastic on the appeal and approval!!
You're right that most doctors don't want to deal with Straight Medicaid. I had to do some serious research, sending emails, etc., to find my surgeon. The closest one to me accepted all of the other Medicaids (Molina, Priority Health), but not Straight Medicaid. I finally had a couple of emails from doctors on the other side of the state and I read them and left them in my inbox for close to three months. When I decided which one to contact, I was thrilled with how warm and caring and full of information they had! I had an appointment scheduled within the following two weeks, but had to reschedule due to a funeral.
When I finally met with the surgeon and his team, they answered all of my questions. My dad (an RNY patient from 10 years ago) went with me so I wouldn't forget to ask specific questions. I left with a folder packed with information, what to do, lists, and such to refer to when I got back home.
I'm coming down the home stretch toward an approval, and I'm hoping that I don't have to do a supervised diet. That would so suck!
