Hi, I'm new! Insurance question...

Hello everybody! I have been lurking around the site to find information about weight loss surgery and it has really started to spark my curiousity. I have one question that I haven't been able to find an answer to and I thought that this would be the best forum to ask it since I live in South Carolina. Please forgive me if I'm asking in the wrong place. My question is about insurance. I am a state employee and I have Blue Choice (formerly Companion) insurance. Does anyone know if this insurance covers surgery? I called them today to find out and they said my policy excludes it. I told the lady that I have an old book that says it is covered if it is medically necessary. She said if a doctor says it is medically necessary that it is covered (it would be medically necessary in my case). What my question boils down to is this: does anyone have any knowledge on this insurance? Does my primary care physician need to refer me to insurance or should I go to a surgeon for a referral? I saw that people with this insurance have had it done in the past few months. Thank you for any help!

I don't have any personal experience with Blue Choice but I looked them up under the Insurers part of OH and found someone that was approved after their first letter just this last October so that is a good sign.

I have MUSC Options (which is a policy of Blue Choice SC). They will pay if medically necessary. What is your BMI, co-morbids, etc? Under my policy, I can self refer at a higher specialist copay or just get a referral from my pcp at regular copay rates. The surgeons office will file with the insurance company so you don't need to deal with sending in claim forms. If you have an HMO, you have to get a referral before you see the surgeon or you will end up getting the claim denied and will have to pay out of pocket for the consult with the surgeon. I hope this helps. I hear that approval is fast with these policies. I'm still saving up leave time at work before I submit my paperwork--I want at least 4 weeks off and I have NO leave as of today

Every insurance company has a written criteria they go by to approve the surgery. Your best bet is to find out what that criteria is and go by the letter. Then they can't (or have a hard time) denying you. If you have an HR Department at your work, ask for their help. I did and it made a difference. They have to keep this confidential if you tell them to! Good luck and keep us posted! Susann

Good Morning, You have to go to your PCP to get your referral to the general surgeon and go from there. Your surgeon's office will submit the paperwork for the authorization to Blue Choice. Good Luck in your journey and welcome to the board, Britt

WELCOME MS CARMEN ... SO GLAD YOU ARE NO LONGER LURKING BUT HAVE DECIDED TO JOIN US!!!!!!!!! I CAN ONLY TELL YOU GENERALITIES OF INSURANCE ... BE EXTREMELY PRO-ACTIVE ... GIVE THEM WHAT THEY WANT & MORE SO THEY DON'T HAVE A CHANCE TO SAY, "NO". INSURANCE COMPANIES COVER A LOT OF PROCEDURES THEY TELL YOU THEY DON'T ... THE SECRET IS TO ALWAYS STATE THAT IT IS "MEDICALLY NECESSARY" ... THEN, YOU USUALLY GET A DIFFERENT ANSWER. ... REQUEST A WRITTEN COPY OF YOUR INSURANCE COMPANY'S CRITERIA FOR APPROVAL FOR WLS ... THEN, FOLLOW IT TO THE LETTER ... BETTER YET, GIVE THEM EVEN MORE THAN THEY ASK FOR. BY THAT I MEAN ... MY INSURANCE COMPANY WANTED VERIFICATION OF CO-MORBS, SO NOT ONLY DID I GET MY VARIOUS DOCTORS TO WRITE LETTERS REGARDING MY CO-MORBS, I HAD MY PRIMARY/FAMILY DOCTOR ACTUALLY WRITE A "LETTER OF MEDICAL NECESSITY" & I WROTE 2 DOCUMENTS MYSELF ... 1 RELATED TO EVERY ACHE, PAIN & MEDICAL CONDITION I COULD THINK OF THAT MIGHT EVEN BE RELATED TO OBESITY (FROM THE PAIN IN MY SHOULDERS FROM MY BRA STRAPS TO HIGH BLOOD PRESSURE & EVERYTHING IN BETWEEN) & I WROTE THE 2nd DOCUMENT ABOUT HOW OBESITY NEGATIVELY AFFECTED MY LIFESTYLE (AGAIN ... FROM NOT BEING ABLE TO BEND DOWN TO TIE MY OWN SHOES TO HAVING TO HAVE NICK HELP ME OUT OF THE CAR OR OFF THE COUCH). ALL THESE KINDS OF THINGS ARE TAKEN INTO CONSIDERATION & IF YOU TAKE THE TIME TO DOCUMENT THEM IN GREAT DETAIL, QUITE FRANKLY ... YOU LOOK LIKE YOU'RE IN MUCH WORSE PHYSICAL SHAPE THAN THE NEXT PERSON REQUESTING WLS. IT MAY BE EMBARRASSING TO ADMIT ON PAPER SOME OF THESE THINGS, BUT IT IS WORTH IT TO GET HEALTHY! ... IN MOST CASES, IT IS BETTER TO START WITH YOUR PRIMARY/FAMILY PHYSICIAN & HAVE HIM REFER YOU TO THE SURGEON (HE MAY HAVE TO GET AUTHORIZATION FROM YOUR INSURANCE COMPANY 1st DEPENDING ON HOW YOUR INSURANCE WORKS). THE REASON I SAY TO START WITH YOUR PRIMARY PHYSICIAN, IF POSSIBLE, IS BECAUSE HE IS THE ONE THAT CAN REALLY DOCUMENT THAT THIS IS "MEDICALLY NECESSARY" (AS IF ANY SANE PERSON WOULD GO THROUGH THIS IF IT WASN'T MECICALLY NECESSARY) BECAUSE HE KNOWS EVERYTHING ABOUT YOU. THEN, YOU CAN ALSO ASK YOUR SPECIALISTS TO WRITE LETTERS WHICH WILL SUPPORT YOUR PRIMARY PHYSICIAN'S CONTENTION THAT THIS IS MEDICALLY NECESSARY. SO, IF YOU'RE ON A CPAP MACHINE FOR SLEEP APNEA, OR GOING TO A DOCTOR FOR YOUR HEART, OR FOR ARTHRITIS & JOINT/SPINE PROBLEMS ... THEY CAN ALL HELP IN MAKING A STRONGER CASE FOR YOU BY WRITING LETTERS OF SUPPORT. ... IT'S EASIER TO DO ALL THE WORK UPFRONT & GET APPROVED THE 1st TIME THAN FIGHT TO HAVE A DENIAL REVERSED SO DO YOUR BEST & REQUEST THE SAME FROM ALL YOUR DOCTORS. DON'T ASSUME THAT THEY KNOW WHAT YOU NEED ... RESPECTFULLY TELL THEM WHAT YOU NEED THEM TO WRITE & REMIND THEM OF CONDITIONS YOU WANT SPECIFICALLY MENTIONED. WRITE THESE THINGS DOWN AS YOUR DOCTORS SEE HUNDREDS OF PATIENTS & CAN'T BE EXPECTED TO REMEMBER EVERYTHING ABOUT EACH ONE. GIVE THEM COPIES OF YOUR WRITTEN DOCUMENTS REGARDING YOUR MEDICAL CONDITIONS & LIFESTYLE IMPACT TO REVIEW. THEY MAY NOT REALIZE HOW MUCH THE OBESITY IS ACTUALLY NEGATIVELY IMPACTING YOUR HEALTH & LIFE. IT'S BASICALLY UP TO YOU, SWEETIE ... I'VE GOT A LONG LIST OF CO-MORBS I'LL POST FOR YOU. GO THROUGH THEM & IF YOU HAVE EVEN THE SLIGHTEST CASE OF ANY OF THEM, USE IT IN YOUR DOCUMENTATION & REMIND YOUR DOCTORS. BLESSINGS FOR YOUR WLS APPROVAL DAWN & NICK

Thanks for your reply. When I first started looking into this surgery, I saw the word "co-morbidities" and I had no idea what people were talking about. The only co-morbidities that I know about is that I have a foot problem, I am pre-diabetic, and I am borderline with high blood pressure. I read your list of co-morbidities on your other thread and it made me realize that I have more that I have not realized were obesity-related or discussed with my doctor. I go to my family doctor in Columbia and I know he has a list of all my medical issues, as I have been his patient for about fifteen years and I have been obese as long as I can remember. I'm seeing him in a week to hopefully get a referral to a surgeon and I really hope my insurance will help. I called Customer Service and they told me that my policy has all weight loss surgery as an exclusion. I asked the representative if it is possible to get it if it is medically necessary and she said "yes, if it is medically necessary." I'm making a list of all diets/exercise programs I've been on throughout my life and I am going to write a letter stating why I feel I need this surgery. I've seen on this website that approval from my company was given just a few weeks ago, so I am hoping for the best. Thank you again for your post. It really helps.

YOU'RE MOST WELCOMED, MS CARMEN. IT FEELS SO GOOD WHEN SOMETHING I'VE SAID ACTUALLY HELPS ANOTHER WLS FRIEND!!! THIS IS A CONFUSING JOURNEY AT TIMES. A LOT OF US DIDN'T REALIZE HOW MANY CO-MORBS WE HAD & WHAT TYPES OF MEDICAL/LIFESTYLE ISSUES THEY ACTUALLY ACCEPT. I STARTED COMPILING THAT LIST FROM POSTS FROM OTHER LADIES UNTIL I ENDED UP WITH THAT LONG ONE. I ALSO USED A LIST FROM MY SURGEON, SO THEY ARE LEGITIMATE. TAKE THE LIST TO YOUR DOC ... MAYBE IT WILL JOG IS MEMORY AS TO SOMETHING ELSE THAT MIGHT BE RELATED THAT WE HAVEN'T LISTED THERE. SO MANY INSURANCE COMPANIES DO THAT ... SAY, "NO" TO A PROCEDURE & IF YOU DON'T KNOW TO ASK "IF IT'S MEDICALLY NECESSARY" YOU NEVER GET THE MEDICAL CARE YOU REALLY NEED. GOOD FOR YOU FOR BEING PERSISTENT & THOROUGH! YUP, YUP, YUP ... WRITE DOWN EVERYTHING YOU CAN THINK OF ... IT CAN ONLY HELP YOUR CASE. GOD BLESS YOU ON THIS JOURNEY DAWN & NICK

I SEE THAT YOU LIVE IN SUMMERVILLE, MS CARMEN. PLEASE CONSIDER JOINING US AT OUR THURSDAY EVENING MEETINGS OF THE LCBB (LOWCOUNTRY BYPASS BUDDIES). WE MEET AT 6:00 TO AROUND 7:30PM BUT YOU CAN COME LATE OR LEAVE EARLY. WE HAVE THE BEST BUNCH OF PEOPLE & YOU'LL GET A TON OF INFO & SUPPORT. BRING YOUR HUBBY OR A FRIEND, OR COME ALONE ... HOWEVER YOU ARE COMFORTABLE. WE MEET AT DIFFERENT RESTUARANTS IN THE NORTHWOODS MALL AREA. MS SUSANN IS OUR CHAIRWOMAN & IF YOU GIVE HER YOUR E-MAIL ADDRESS, SHE'LL SEND YOU A GROUP E-MAIL AS A REMINDER & WITH WHAT RESTUARANT WE'LL BE AT ... OR, YOU CAN LOOK ON THE BOARD HERE. HOPE TO SEE YOU NEXT THURSDAY ... GOD BLESS YOU DAWN & NICK

Thank you very much! I'll have to check it out!