Atrium/Badgercare experience anyone???

I am in the process of my journey to weight loss surgery and would like to know of anyone's experience with the Badgercare/Atrium insurer, so I know what I will be faced with. Any suggestions as to dealing with them would be very helpful for me. My BMI is 48.3, and I have terrible joint and back pain and am very limited as to what activities I can do. Thanks!

Tiffany, I also have BadgerCare Title 19. My experience with them has been fustrating at the least. I was denied because of a Medical Neccesity clause with in the Wisconsin Administration Code 107.02(3)(e). Calling the insurer is of little help. I called them several times before I even seen my doctor and asked specifically if they would approve WLS and the answer I got was yes if it were deemded medically necessary. I have a BMI of 41.6 with comorbities, Diabetes, sleep apena, and severe back pain that will require more surgery if I dont loose weight. That being said I was still denied. I did some research and found out that it was lack of information on my part is the reason for denial. Below you will find a copy of the Guidlines that BadgerCare uses to approve or deny WLS surgery. I hope it helps. I believe with the additional info I submitted that I will be approaved in round two using the same Administration Code they used to deny my first atempt. My advice to you is stay on them and gather as much info as you can to help your claim along and never give up. I was told as long as you meet the guidlines you will be approved. It may take some time but it will all be worth it in the end. Dont be afraid to put on the proverbial boxing gloves and duke it out with them. Good luck with you venture and let me know how things turn out. Hope the below info helps to answer some of your questions. ATTACHMENT 9 Physician Services Requiring Prior Authorization Gastric Bypass/Gastric Stapling / HSF101.03 (96m) Wis. Administration Code Gastric bypass or gastric stapling is approved only under very limited cir****tances, as determined by the Department of Health and Family Services (DHFS). All of the following must be true of the recipient. ·Acceptable operative risks and be able to participate in treatment and long-term follow-up ·Body mass index (BMI) of 40 or greater or between 35 and 39 with high risk co-morbid medical conditions clinically judged to be life-threatening, such as documented sleep apnea, Pickwickian syndrome, obesity-related cardiomyopathy, or severe diabetes mellitus. The provider is required to supply evidence of the recipient?s repeated failures to lose weight using physical, medical, and psychological means. Evidence that a psychological evaluation has been performed prior to the gastric surgery is good medical practice. Wisconsin Medicaid and BadgerCare Service-Specific Information HFS 101.03 WISCONSIN ADMINISTRATIVE CODE (96m) "Medically necessary" means a medical assistance service under ch. HFS 107 that is: (a) Required to prevent, identify or treat a recipient's illness, injury or disability; and (b) Meets the following standards: 1. Is consistent with the recipient's symptoms or with preven-tion, diagnosis or treatment of the recipient's illness, injury or dis-ability; 2. Is provided consistent with standards of acceptable quality of care applicable to the type of service, the type of provider and the setting in which the service is provided; 3. Is appropriate with regard to generally accepted standards of medical practice; 4. Is not medically contraindicated with regard to the recipi-ent's diagnoses, the recipient's symptoms or other medically nec-essary services being provided to the recipient; 5. Is of proven medical value or usefulness and, consistent with s. HFS 107.035, is not experimental in nature; 6. Is not duplicative with respect to other services being pro-vided to the recipient; 7. Is not solely for the convenience of the recipient, the recipi-ent's family or a provider; 8. With respect to prior authorization of a service and to other prospective coverage determinations made by the department, is cost-effective compared to an alternative medically necessary service which is reasonably accessible to the recipient; and 9. Is the most appropriate supply or level of service that can safely and effectively be provided to the recipient. for direct reimbursement, who is in single practice rather than group practice, or a provider who, although employed by a pro-vider group, has private patients for whom the provider submits claims to MA.