State Medical and WLS PLEASE HELP!!!

Hello, NEW HERE! Been looking into getting WLS & currently have LA Care Medi-Cal....I can choose different plan providers such as anthem, care 1st and Kaiser...but first, anyone get lucky with LA Care in getting approved for surgery? If not, any one get lucky using the other plan providers with MEDI-CAL? Been trying to search for answers for months...(p.s. I did call LA Care they say they will cover if deemed "Medically Necessary"....i feel that they might BS me with some crap that they will say no to the surgery) 

Pretty much all insurance plans with WLS coverage will only do so when "medically necessary," so that's not something special to LA Care. You may want to call and see if you can get a list of criteria they require to deem WLS medically necessary-- that'll often include things like BMI, health history, comorbidities, and documented diet attempts.

Hope this helps because I've been on the other side of the phone, so to speak, as when I had my rny it was when I worked in medical review for one of the nation's largest health insurance companies and I had to be in the position of telling people who had employer sponsored insurance programs that they didn't qualify or that bariatric surgery was an exclusion. 

Even more ironic was that for us employees, ourselves, bariatric surgery was an exclusion. 

Other people might be able to chime in with specifics about health documentation, what to do to know to expect with your review. I could do it, too. But I'm not going to bother and I'll tell you why. 

This is the point I'm trying to make, you can't take this personally. None of the process, is PERSONAL . Insurance companies whether it's Medicaid or if someone has insurance through their employer. And the entity sponsoring the insurance benefit through the specific insurance company dictates coverage. Not the insurance company themselves, but they'll usually offer services to said entity, to help reduce the claims they pay out.

That's it. It's not that you could be denied bariatric surgery because the insurance company or the person on the phone doesn't like you. It's not because they want you to die from weight related reasons and/or not have the opportunity to be thin There is only really ONE reason why bariatic surgery is covered and it IS usually covered with requirements, for this reason ONLY.  

Bariatric surgery gets covered, basically based upon some kind of formula that's going to help predict in the both short and long term, that they will be paying out less in claims due to bariatric surgery than they would be if a patient gets a co-morbidity that's traditional of Obesity. Such as having to pay out claims for diabetes, sleep apnea, high cholesterol 

The only reason why it's changed in the last 15 years since I had my gastric bypass,  due to the participation of sites like OH, OAC, surgeons and wls patients who advocate for standard criteria that's reasonable, for a patient to have coverage. 

So this is why I'm telling you not to take it personal, if the surgery is not an exclusion (which still could be appealed, but doesn't sound like your cir****tancs) why you have criteria. And most importantly why you CANNOT take it personally. This is just one step. Even if you get it covered, you still have to go through a surgeon's process. Sometimes they have to postpone appointments. Sometimes they have to postpone your surgery(didn't happen to me, but a few others I've known in the 15 years I've participated in the wls community) then all the changes that go through that. 

I had to fight and I did take it personally, given the fact I was fighting my actual employer. They made it much more difficult to get my rny than it should have been. It also made it much tougher on me, even though I didn't take it personally (I live in the State of MN, in 2001, if you worked for a big insurance company like I did, you actually had to have health insurance from a DIFFERENT company) so it's not like I know this because I was so gracious, cause I wasn't. I learned all of this really the hard way and I'm really trying to spare you from unnecessary aggrevation.

And I am wordy and I can't give advice at all, without explaining the WHY of what I'm saying. If this doesn't make sense, please feel free and I'll try to elaborate. 

Hi clowedy911  

You have gotten some great direction and advice.  I called UCLA (not sure where you are located) and asked if they take Medi-cal for another member a couple of months ago http://bariatrics.ucla.edu/

I spoke to Mel at this facility and she had great information. Her location does not take Medi-cal but Dr. Sergey Lyass, 310-623-1786 does. However, she said you have to have straight Medi-cal. If it's associated to an HMO then you have to go through your PCP. Here is some information on the surgeon and facility.

https://www.marinahospital.com/weight-loss

Talking to a surgeon's coordinator that deals with insurance on a daily basis can be a great source of information and help you navigate what program works best for you and what program works best for finding a surgeon.

Keep us posted on how things go