Scared of not getting Approved

CGervolstad2385
on 9/8/14 6:07 pm

I currently have Anthem Blue Cross medical program for insurance and I have gone through every step that medical requires I am diabetic and also have sleep apnea I'm afraid of getting everything done and then the insurance  denies the surgery. Has anyone had there surgery done and had the same insurance I am in california 

Heather B.
on 9/9/14 12:55 am - Wyandotte, MI

I have Anthem from Cali. My company HQ is in Cali. I was approved twice (the original surgery and the revision) and my husband was approved as well. You have to be 100lbs overweight (generally) or have other issues which you do. If you meet the requirements and jump through their hoops you should be fine.

Heather B. 
VSG on 11/28/11
Revision to RNY on 04/28/14

        

Luvmygs
on 9/9/14 2:40 am
VSG on 12/04/14

I have anthem Blue Cross and I'm now awaiting approval for WLS. Early on I contacted Anthem and asked if they covered this type of procedure and they emailed me a full description of the medical policy. This is just a part of the information they sent me.


Gastric bypass and gastric restrictive procedures with a Roux-en-Y procedure up to 150 cm, laparoscopic adjustable gastric banding (for example, the Lap-Band® System or the REALIZE™ Adjustable Gastric Band), vertical banded gastroplasty, biliopancreatic bypass with duodenal switch, and sleeve gastrectomy (open or laparoscopic) are considered medically necessary for the treatment of clinically severe obesity for selected adults (18 years and older) who meet ALL the following criteria:
1. BMI of 40 or greater, or BMI of 35 or greater with an obesity-related co-morbid condition including, but not
limited to:
diabetes mellitus; or
cardiovascular disease; or
hypertension; or life threatening cardio-pulmonary problems, (for example, severe obstructive sleep apnea, Pickwickian
syndrome, obesity related cardiomyopathy); AND
2. The individual must have actively participated in non-surgical methods of weight reduction; these efforts must
be fully appraised by the physician requesting authorization for surgery; AND
3. The physician requesting authorization for the surgery must confirm the following:

The individual's psychiatric profile is such that the candidate is able to understand, tolerate and comply with all phases of care and is committed to long-term follow-up requirements; and
The candidate's post-operative expectations have been addressed; and The individual has undergone a preoperative medical consultation and is felt to be an acceptable surgical candidate; and The individual has undergone a preoperative mental health assessment and is felt to be an acceptable candidate; and
The individual has received a thorough explanation of the risks, benefits, and uncertainties of the
procedure; and
The candidate's treatment plan includes pre- and post-operative dietary evaluations and nutritional
counseling; and
The candidate's treatment plan includes counseling regarding exercise, psychological issues and the
availability of supportive resources when needed..

poet_kelly
on 9/9/14 4:49 am - OH

If you have done everything your insurance policy requires and you meet their criteria, they will have to pay for surgery.  They  must follow the rules in the policy you have purchased from them.  They can't just refuse to pay for no reason.

View more of my photos at ObesityHelp.com          Kelly

Please note: I AM NOT A DOCTOR.  If you want medical advice, talk to your doctor.  Whatever I post, there is probably some surgeon or other health care provider somewhere that disagrees with me.  If you want to know what your surgeon thinks, then ask him or her.    Check out my blog.

 

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