Insurance question???

Hey, everyone!(:

I called my surgeons office yesterday to see where I'm at exactly in the process of testing, approval, etc. I was told that my papers and documents were sent in to my insurance for approval. (I do have coverage)

Here's the thing, according to my insurance and policy it says: For a member to be considered eligible for benefit coverage of bariatric surgery to treat morbid obesity, the member must meet the following criteria: 

2. Documentation from the requesting surgical program that:

• Growth is completed (generally, growth is considered completed by 18 years of age); AND
• Documentation from the surgeon attesting that the patient has been educated in and understands the post-operative regimen, which should include ALL of the following components:

1.     Nutrition program, which may include a very low calorie diet or a recognized commercial diet-based weight loss program; AND

2.     Behavior modification or behavioral health interventions; AND

3.     Counseling and instruction on exercise and increased physical activity; AND

4.     Ongoing support for lifestyle changes to make and maintain appropriate choices that will reduce health risk factors and improve overall health; AND

(There is more criteria, but I have already met it.)

My required one-time nutrition consultation is scheduled for this coming Monday but my surgeons office has already sent in the documents to insurance for approval.

My question is:

Since I have NOT had my nutrition consultation yet, will my request for surgery be DENIED until I have it done?

I DID call my insurance company and verified they received my documents. I also DID ask my question to the woman I spoke with and she said she didn't know. I will be calling back Monday, but in the meantime, I was wondering if anybody could shed some light on this.

I appreciate all answers and help!

xoxo,

MommyOfTaeya

It sounds like it can be any program that you have done in the past.  Do you have Weigh****chers, Jenny Craig, or some other group that can provide records.  Have you been under doctor supervised programs in the past?   I gathered all my records from those attempts and also went through a nutrition program where I say the dietitian once a month at my surgeon's office.

Even though your records have been submitted to the insurance company, if you have documents from older programs, you can send those in to be added to your file before a decision is made.

If you don't have former supervised diet records, then it will just be a judgment call by whoever does your review as to whether they want you to do a supervised nutrition program before they approve.

I have done WW but I have no documentation of it.

Thank you for the reply!

xoxo,

MommyOfTaeya

They were able to provide me with my documentation.  That was eight years ago so it might be different now.  Call them at 800-651-6000 

Yes Weigh****chers was able to provide me with a weight record just this past year, but only for the times when I bought the pre-paid program. They may send the Dr.'s office a letter requesting the missing information, and if they deny it because it's incomplete it doesn't mean they can't resubmit.

Do you have to provide written documentation from WW or whatever that you have gone thru their program or can you provide certain dates that you remember that you went? When I was going thru the process I just made up dates in my head cuz I sure couldn't remember what dates I went. Did you pay for any weight loss programs by credit card? You might be able to provide them with a receipt of that as proof that you did go thru their program that the ins might take.

Did you do any kind of 3-6 month weight loss trial with your physicians office?  (Or did they provide you with any paperwork about healthier eating during multi month visits?). If so, it will likely be what the doctors office uses to meet that criteria.

My insurance does not require a weight loss program of x months. They just need a one time dietitian consultation. 

Thank you for all of the replies.

xoxo,

MommyOfTaeya

Unfortunately, the insurance company can deny the request for authorization if their criteria for surgery is not met. The surgeons office should know better! It may prolong the process and require you to appeal their decision.  Good luck!

Call the insurance company on Monday and ask them if they have everything they need.  This will give you a chance to get anything missing to them before they deny it because you didn't meet requirements.