Insurance Coverage criteria

Hi there -- I was browsing through the mesage board and saw there were lots of questions about insurance coverage and thought I might be able to offer some help and insight when trying to deal with the insurance company nightmare. I am 6 yrs post lap RNY having been 314 lbs at 5'8" with a BMI of 45..... I am now 137 lbs with a BMI 20. My surgery was done back in NJ by Dr. Andrei. It was really easy back then compared to now, a good history & physical from the surgeon was pretty much all it took to get covered. .... i have been invloved in this stuff for a long time now and over the past few years as the various proceudres have become more and more popular the insurance companies and employers have put major obstacles and criteria in place and surgeons no longer have the ability to override an exclusion or the criteria in place. Often when you call your insuracne company you will get 2 or 3 different stories because you are usually calling an outsourced call center often located in India. Insurance companies also change their policies at their whim usually without any prior notification to your surgeon or to the insureds. The other problem is that althougha company such as UHC offers coverage with easiest criteria each employer and each division within an employer can opt to place an exclusion or their own criteria. Often you dont find this out until it goes to "medical review" -- Each policy will state that coverage is subject to "medical necessity review" which is their catch-all to deny you even if you have followed all criteria you were given -- With an "employer exclusion" forget fighting it yourself --- visit www.obesitylaw.com to chat with Walter Lindstrom, Esq. So heres some tips.... First, know your insurance CPT code for your procedure.... ask your surgeon (or prospective surgeon's office ) for it -- the most common ones are listed here: Insurance companies can look up the code and give you information LAP BAND -- Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric band use CPT code 43770 For Vertical-Banded Gastroplasty- use the CPT code 43842 Other gastric restrictive procedures, without gastric bypass, and other than Vertical Banded Gastroplasty- use the CPT code 43843 Gastric restrictive procedure with gastric bypass for morbid obesity; with short limb (150 cm) Roux-en-Y, use the CPT code 43847 SECOND -- have pen, paper and time to write down all the details and names of who you spoke with at your insurance company --- Give the correct CPT code and ask if it is a covered benefit - THIRD -- ask for the coverage criteria such as (A) 6 consectutive month within past year (or even up to 1 yr or more of a) medically supervised diet (does not include Jenny Craig, weigh****chers, etc) it usually means you have to go for monthly weigh ins with nutritional counseling and exercise instruction - document your notes carefull and have your doctors make detailed noes -- Usually the insurance company does not allow the surgeon to monitor your supervised diet which means you have to go to your PCP each and every month for the time.-- if you miss a month they will make you start over (B) letter of medically necessity from PCP or other treating doctors (C) psychological exam with an MMPI or maybe without it; (D) 3 to 5 years medical records --- this one is important - they are looking for actual chart notes documenting your weight and comorbid conditions during the last several years - a letter from you or or PCP simply stating this things will not work with Aetna, BCBS, Humana or CIGNA, (E) EKG? Cardiac clearance? (often if you are 50 or above you may be required to have one if not by insurance by your surgeon) (F) pre-op weight loss (10%? or certain amount of pounds?) (f) some even require a prior prescription drug therapy (Meridia, etc) or have your PCP document why you could not take a drug (G) BMI requirements --- many companies as of 1/1/07 are now requiring a strict 40 BMI or above - or a 35 with "severe lifethreateneing co-morbiditites" In fact I know BC of California and the BCBS State of AZ plan do not consider diabetes that is controlled with insulin or hypetension controlled with meds are life-threatening , however a CPAP machine (not just suspected sleep apnea) is considered life-threateneing --- its ridiculous but that is their written policy. FOURTH - be diligent about getting all of your records faxed to your surgeon's office or if you have the information prior to you first consultation you can bring records with you --- FIFTH --- Insurance companies often will not take verbal notification so everything has to be faxed and then you have to wait till they get it uploaded into their system and assigned to a review nurse or case manager. That can take a week or 2 from when your surgeon's office submits -- claims will not have the information as a request for pre-authorization is not a claim --- -- You can usually find out a status by call the care coordination, care notification or prior auth departments for an update --- however they will state they have 30 business days to render a decision. Once you receive a written decision fax it to your surgeon (patients usually receive their written letters first) You want the written because a verbal means nothing until you have the paper in hand. SIXTH - a limited time frame for the approval is common for insurance companies to impose such as 30 or 90 days within which to have your surgery. Also keep in mind that cHanging an approval from one surgeon to another IS NOT as easy as a simple phone call --- Most often requires re-submission although with a prior approval the process may go a little faster. Hope this helps a little. Good luck to everyone!!!!

hi Darcie - since you had your surgery 6 years ago, i think your info is a bit outdated. I recently had surgery in Nov 06, and my approval process was quick and painless. My insurance no longer requires the 6 mos documented diet (they USED to). I have heard that most insurance co's do not require this, although some still do. Nor was I required to provide any sort of "letter of medical necessity" as was previously required. My surgeon examined me, I had a BMI over 40 (no other co-morbidities) and was approved within a week. the process is much shorter and less painful that it was even a year ago when I first started investigating surgery. I think anyone who wants to should give it a shot ! Sue

Darcie - Thank you for sharing the information. I think it is right on, and very nice of you to share with the board. I have heard the same as you that the insurance companies are indeed making the process more difficult. As Nicole had written in an earlier post it is important for everyone to have all their ducks in a row before they go in so that they are prepared for what the insurance company is going to ask for. My doctors were ready with all the tests, diet plans, medical history and everything for me to fight my insurance company, but they flat out refused to even consider me and I ended up paying cash for my surgery in November. I know at that time I had spoken to people in the chat rooms that had been fighting with their insurance companies for up to 2 years! Sue - I agree everyone should give this a shot! Absolutely there is nothing more important then one's health. I sacrificed a great deal to have mine regardless of the insurance, and it was by far the absolute best investment I ever made! I don't think anyone should let the insurance stand in their way. I'm so glad your process was quick and painless. I wish more insurance companies were as committed to patient care and health as yours. You may want to consider posting what your insurance company is. That might actually be a good idea for a new topic. No hassle insurance companies. I think that would be helpful for people looking to switch insurance companies, or get self insured. I know I have seen people on the board asking questions like that before.

Hiya Sue! Darcie's info is actually as up to date as is possible. I used to work with her at Dr. Simpson's office and one of her specialties is weight loss insurance. She gets the notices as soon as they are posted. The thing about insurance though is that 5 friends could all have United Health Care insurance and work for 5 different companies and have 5 different sets of qualifications for an Rny and another 5 sets for LapBand. That's why those codes that Darcie listed are so helpful. In fact, we would tell every patient that called us to call their insurance first with those specific "codes" to find out their unique set of details. You are soooooo fortunate to have sailed through your process! So, how are you doing now? Did you get your LapBand support information from ST Luke's? .... How bout joining us at one of our Chandler support groups some time soon? We would love to have another Bandster! .......I pop in on occassion to the St Luke's events too so maybe we'll bump into each other some time! Huggggzzz to you! Joyce

Thanks Darcie, that is some great information. It never hurts to have this kind of information "just in case". I definately want to reiterate to everyone to get things in writing! Before our company changed to Cigna, I was promised the world. "oh, dont worry, as long as you are certified, we will just pick up where UHC left off". YEAH RIGHT! Had I gotten something from Cigna saying this, then maybe I would have had a leg to stand on. Anyway, now all of my information has to be resubmitted and I may have to do the 6 mo. diet plan! I have no idea how this is going to handle my April 3rd, surgury date.... Has anyone been able to successfully fight the diet plan? If so, shoot some info. my way, K? Chow, Dawn