Insurance -- Pre-approvals, appeals, and other stuff I need help with

tldr; I want to have my WLS by the end of this year, not a year from now, and I need advice on how to get my insurance company to loosen up a little on their requirements.

Okay so, I've already had some input from some lovely ladies on a blog post of mine... but I'm looking for a little help/input on something I'm trying to orchestrate. The longer version of my story goes like this;

• I am "morbidly obese" (BMI ~58/59) and 100% qualify for WLS under my insurance plan, they only require that I have a BMI of 40+.
• However, like many insurance companies, they want me to have a "medically managed diet period" before surgery. Which is fine, but it is 12 months and that seems WAY too long, considering I've been "obese" since at least age 14 (yeah, I know).
• I went to a surgical weight loss group, they got me signed up and then suggested I do the first 6 months with my PCP and the last 6 months with them. So, I went to my PCP and told them I needed to 'check in' for the first of my six months, which I did, though they were confused as to why--since I had been going there for years and have a consistent weight trend on file. They are drafting up a "letter of medical necessity" which I have also done.
• I contacted the surgical WL group and talked to the woman who is overseeing my file. She said in her experience, insurance companies want to see 6 consecutive months of weigh-ins. And did not seem to think that my letter would be enough.

So... what I'm trying to figure out;

1. Maybe she didn't understand? I'm not trying to skip the whole 12 month diet. I just want to skip the first 6 months, since my PCP seems to think that the information and co-morbidities they have on file will be enough to convince my insurance of the necessity of the surgery and of our continued monitoring of my weight.
2. Could I submit my letter and the letter from my PCP asking for pre-approval with a 'shortened' version of the diet plan? How would I go about doing that? Does it have to go through the surgical WL group I'm going to use? Or could I obtain pre-approval kind of like you do in the finance industry and send that to the woman overseeing my case in order to start on their program??
3. Has anyone else been in this boat? What did you do and what would you recommend?

Also, entirely unrelated to the topic above... but I am going for a VSG. I'm 348ish 5'5'' female 27yo... my goal weight is between 140 and 160. How doable is that with the VSG? I've heard tell that for that kind of weight loss, I should be looking at a bypass instead (especially since I have GERD). I really would rather not end up having to do a revision.

Thank you in advance for any help!!

It is VERY difficult to get insurance companies to "loosen up" on their restrictions; in over 6 years on OH, I've yet to see it happen.

Some people are able to fulfill the pre-op diet requirement by providing documentation from previous diet attempts within the recent past. But these usually require external validation-- logs of payment and weigh-ins from Weigh****chers or a physician.

Simply saying "my doctor thinks I'm fat enough to skip the diet" is almost always insufficient. The insurance company wants to stick to a diet for 12 months to prove that you will be successful after surgery, and that they aren't wasting your money.

Related to your surgery question: if you have GERD, you should absolutely avoid the VSG. It is known to make acid problems worse, and there have been many patients here on OH who have to revise from VSG to RNY because of worsening (or brand-new) GERD.

Thanks for your input. So should I not bother trying to get pre-approval/appeal? I'm pretty sure I'll still need the letter from my PCP when they do actually submit for approval later. I am kicking myself for not having better documentation. All I'm missing is March in terms of "6 consecutive weigh-ins" and I've got food logs going back to the beginning of the year (some paper logs, some on an app), "before and after" photos from some of my diets/programs as well as a running tally of my weight with it... but nothing I can point to and say that others verified it at the time -_-

And as for the surgery: yeah, I think I'll have to talk to the surgeon. I seem to be getting a lot of feedback that says it will worsen my GERD. I guess the malabsorption aspect always worried me. Thanks for your help!

Yeah, I think you'd probably just waste a lot of time trying to appeal the requirements. You'll likely need a referral letter from your PCP generally saying "this person knows what they're getting into and I approve them for surgery, but a recommendation of a shortened diet probably won't fly.

The malabsorption can be worrisome, but as long as you stay on top of your vitamins, you shouldn't have too much trouble. You can meet the ASMBS guidelines by taking a double-dose of a complete adult multivitamin, plus additional calcium and iron supplements. Once you get into the habit of taking your vitamins, it's not a big deal!

Thank you again!

Definitely going to bring this up next time I meet with my surgeon.

Hi Vampy,

If that is what is required to get your insurance to pay there is no way around it, unless you have the option to change insurances. I can only give you my experience. The diet is more of getting you ready, changing your life style, showing you can do it. When I went to see my surgeon the 1st time I told him I need this surgery and I need it now. If you give me too much time to think about it I will chicken out. He smiled and said it was nice meeting you but my program is not for you. My program is a good 6-12 months. I was in tears, walked away with the resolve I was going to do it myself this time and got back on that Merry Go Round.

I agree 12 months is a long time, but how many years did it take you to get to where you are today? The number 1 thing you can do during this time is to deal with your head issues. Trust me, I have seen it for the last 15 years. Those that get to goal and stay there are the ones that tackled the reason/s we eat in the first place. Identify why we turn to food and 1 by 1 worked on those issues. By the time your surgery date is set you are going to be armed with all the tools you need to be a long termed success. When I talk to people I tell them (and they don't always like to hear this) "YOU HAVE TO GET IT RIGHT BETWEEN YOUR EARS BEFORE REARRANGE YOUR PLUMBING". The time I spent in my surgeon's program was the most valued of all the things I did getting ready for surgery

You can do this and we have your back As far as the type of surgery, I had RNY, weight was 330 and it was the best thing I ever did to save my life. Discuss your options over with your surgeon as he/she knows your medical issues and history and you guys can come up with the best option for you.

We look forward to your updates!

P.S....If you have not done so, post this on the VSG forum too

I guess where I'm frustrated is that I have been changing my diet in anticipation of this since the beginning of the year. I had an appendectomy in January and that was when I got a referral for the WLS office. So I took the opportunity to begin correcting my diet, knowing I would need to do so for surgery anyway. (No soda, boost in protein, no fast food, smaller portions, etc). I didn't look deep enough into my ins. companies requirements so I was expecting a 6 month waiting period and didn't think I would need to visit my PCP beforehand.

Oh I am definitely standing in line for that merry-go-round ready to kick some plastic pony booty--I guess I'm wishing I had a "FastPass" like an amusement park would :P

I guess I'm going to have to bring this to my therapist, maybe he'll help me feel less impatient about it too ^^;; I know it took me a long time to get here. I suppose as long as I'm under 300 by my 30th birthday I can count that as a success lol

Thanks for your input/advice.

(about posting, I will do that :) )

Check out the post from Member Services. She has years of experience with insurance, so you may be able to get the credit you are looking for.

Thank you

Though I can't answer your question about the insurance requirements and trying to get them to loosen up.

I can say that if you currently have GERD I would strongly suggest not getting the VSG.

Now I am not saying the VSG is a bad surgery because it is, but it seems when folks who have a history of GERD/reflux/heartburn/etc. get the VSG it ends up making it worse and they end up having to revise to the bypass at some point some sooner than others.