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

Yeah I really am not trying to have to get a revision. I know my surgeon said it's 'easy enough' to revise, but that doesn't account for recovery time and time out of work lol

So I guess I'll talk to them about it the next time I'm there.

Thanks for your input!

the other thing about revisions - many insurance companies will only cover one WLS surgery per lifetime. Although it could be that if it's medically necessary to revise, they might be OK with it. But I would also stay away from VSG if I had GERD. In fact, I DID have GERD, which is why I went with the RNY.

Yeah I'll definitely have to bring this up and see what the surgeon thinks.

Thank you!

I have worked in the insurance field for 20+ years and generally if you saw your PCP on a monthly basis and they weighed you and he/she discussed your need to lose weight along with what you are doing and need to do, this would suffice.

However, you will need to submit office notes to demonstrate this to them and these should accompany your letter of medical necessity that your PCP does. Your PCP can also attest in the letter that you are actively attending a weight loss group, monthly as well.

Good luck!

I think I might have to suffer with the twelve months, because my documentation isn't very good. I am missing a couple of months between December and now for check-in's with my doctor and I think that's what's really going to do me in. We talk about my weight every time I go, ofc. And I have been losing, slowly but surely, since February. But maybe after I do the six with my PCP, I can use that and not have to do the entire 6 with my surgical team (they said 3-6 for their program, so perhaps there is still a chance of getting WLS as a wonderful Christmas present haha! Or perhaps around the first of the year... who knows)

Thank you for your input!

check with your insurance company. Mine was fine with me doing it either with my PCP...or another doctor...or a registered dietitian. It didn't matter if they were on my surgical team or not. As long as it was supervised by a professional, they were fine with it.

I think maybe I'm not getting in touch with the right people. I've called my insurance company twice not to try and see what the requirements are and all they do is read me the same sentence from my benefits booklet.

I honestly don't care where I go, I only want to go to the surgical center so I can attend their classes at the same time.

Does it state that it has to be a consecutive 12 months? I had a 6 month requirement which could be satisfied by 6 physician visits where we discussed my weight (per doctor notes) over the prior two years. I found that out when I called the insurance company (I thought they had to be consecutive). Just make sure you completely understand their requirements by talking to them. Once they are clear, as the others said you'll have to adhere to those requirements.

Okay so I had to go back and look, after this and a couple of other comments. And my benefits booklet says; "Benefits are also provided for surgical treatment of morbid obesity (bariatric surgery) if you have received 12 months of medical management for this condition prior to the surgical procedure, supervised by your DOCTOR or OTHER PROFESSIONAL PROVIDER" verbatim. It does not specify consecutive. And, if it's the case that they don't have to be consecutive, then I only need to go once more to have had six months in the past 2 years.

I don't know where else I would look to find any more in-depth information. It does say that it requires prior review and certification, but doesn't direct me to any further qualifiers/disqualifiers.

edit: I only heard 'consecutive' from the surgical team.

Have you talked to the insurance company? The surgical team likely deals with many types of insurance, so may not know what your insurance requires.