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

Every time I call, all they do is read me that same sentence lol. I'm not sure if I'm being put into a call center and they're just reading a script or what, but literally that same sentence is the only info I've gotten twice. This last time, I asked the lady I spoke with several questions and she couldn't clarify because 'it would have to go to the specialists who approve it' and I guess they don't say yea or ney unless they have documentation in front of them?? idk

By that statement, they are not requiring specific monthly weigh ins or checks, but rather just a 12 month supervised program. There may (should be) the policy bulletin somewhere on the company's website that gives all of the detailed requirements that may only be summarized in the benefit booklet. The policy bulletin is their legal document against which regulatory appeals are judged. The Aetna policy that covered me (at the time, things may have changed since) only specified a six month medically supervised diet/exercise programhe, with certain documentation requirements, etc. (specifically not just an MD's letter of necessity...) but not specifically monthly or six appointments. Between my PCP and my schedules we only worked in four meetings at roughly six week intervals, and that was fine. YMMV depenhding upon their fine print. Other companies may specifically call for 6 (or 12 or whatever) monthly boxes checked off.

Check with your surgeon's insurance coordinator, as it is (or should be....) their job to know the in's and out's of the various insurance policies as they apply to their practice (or at least the most common companies in your area.) The guy that worked for my surgeon was a stickler about following the specific instructions in the company's policy bulletin, and was upset about how my PCP was formatting or submitting things - he wanted to have all of his ducks in a row to submit things to the insurance so that they couldn't find any reason for denial; hopefully your surgeon has someone as thorough that can help you on this.

Okay so, they sure buried it deep on their website but I believe I've found the policy guidelines (outside of my benefits booklet) that have a more in-depth description of what I need. I'm going to send the screen-shots to my "navigator" (which, is what they're calling what I assume is the insurance coordinator that you're talking about). I don't see anything about weigh-ins or that it has to be 12 consecutive months, it just says "within the past twelve months" I have to have been properly educated, assessed physically and mentally (with a list of what tests I need and what qualifies), and consulted with a nutritionalist to prepare a diet plan that meets the ASMBS guidelines. And, of course, that after I do all of that I have to submit it to prior review in order to make sure I meet the guidelines for surgery.

So I think I'll send the screen grabs, my weight trends for the past two years, and my PCP's letter to the "navigator" and see what she says. Like you said, she would hopefully know the ins and outs of whats going on.

Thanks for your input!

Ask your insurance company for a written copy of their medical necessity criteria for bariatric surgery. That will give you a detailed description of the requirements for WLS approval. That is the tool that they used to approve or deny coverage.

you'll probably NOT be successful in getting your insurance company to revise its guidelines for you. It's sometimes hard enough dealing with them when you meet all their qualifications. They can be a real PITA, to be honest.

I started my six-month supervised diet a year before my surgery. I had to switch insurance plans to one that covered WLS, and my new insurance didn't start up until January. But they accepted a six-month supervised diet any time within the last two years, so I figured I'd get the six-month diet done and over with while I was waiting on my new insurance plan to start up. It was fine - the time flew by. Plus since I was dieting for a year before my surgery, I ended up losing 57 lbs before I even had surgery.

Yeah that seems to be the general consensus I'm getting. I am trying to lose weight before the surgery, I'd like to be at or below 300 by the end of the year because I've been able to do that by myself in the past. And then I guess hopefully maintain until surgery. I've had a couple of people tell me the time will fly by, I sure hope so. I'm tired of being this way -_-

Thanks for you input!

My insurance required a six-month diet. Then we realized that they would accept three months of diet, combined with three months of a supervised exercise program. I had my first appointment with the dietitian on May 20, second on June 15 and third on July 10. I also went to Curves every day and had a document from them.

I'm hoping I'll be able to do something similar here, I'm digging through my policy but I'll have to wait til Monday to call and talk to someone. *sigh*

The only thing I have to document my exercise is my "fitbit" (it's not really, but it works the same way). I wonder if they would accept the logs from that if I needed some evidence.

Thanks for the input!

I don't have any advice regarding the insurance issue. However, I absolutely have advice concerning getting VSG with a history of GERD. DON'T DO IT!!!!!!!!!!!!!!!!!!!! Do not do it!

There are some surgeons who feel as though just because you have Gerd prior to surgery that it may not continue after surgery due to the fact there is a decrease in the abdominal pressure which can help relieve GERD. However, this isn't always the case. If you want to take a chance of having a revision then go ahead and have vsg but consider in the meantime you will be suffering with it until you can get the revision.

I definitely wish I had a crystal ball and could have know what was ahead of me after VSG. A life of living hell dealing with reflux every single day for two years and 3 months is what I've been dealing with. Add to that I've been waiting 6 months for my revision as well!

If you have vsg just keep in mind there's always a possibility for a revision in the future. Just my two cents.

Thank you for the advice.

I definitely feel like I need to see both sides of the coin. I hope you'll get to have the revision soon :((

I for sure wouldn't look forward to that. Though I guess no matter which I do, I'm gambling on how the outcome will be.