Decided on DS, need assistance with Priority Health & the process

I am 5'9" and approx 255 lbs, with my highest having been 300 lbs. Like most everyone here, I have struggled my whole life with obesity/weight issues. I have finally decided on weight loss surgery as I am sick and tired of living this way.

My insurance is Priority Health HMO. I have to have a 6 mo supervised diet with my BMI being 38. However, if the BMI is under 40 Priority health requires at least one co-morbid. I have none, but I know it is a matter of time.

My question is this... Do you think Priority Health will cover me WITHOUT the co-morbid? Or should I try to gain to get up to the 40 BMI which does not require a co-morbid? I hate to consider gaining. I have worked so hard to lose what I have lost over the last couple of years.

Also, say I lose a little bit of weight during my 6 months supervised diet and get below a BMI of 35 (minimum requirement for priority health) - does that mean they will not cover my surgery? 

I have contacted priority health on these questions but they don't really answer them and give me the run around. I have requested their Bariatric Surgery policy but haven't received it yet.

Do I meet with a surgeon before I complete my 6 month diet? Dr. Kenmeeter from GHP comes up to our hospital and is affiliated (where I also work) so I would like to have him do the surgery. Thanks in advance for any insight you may have. I have an appt Wed. to meet with the doctor on starting the 6 month process.

I don’t know if this will help, but I will tell you what I know about Priority Health.   I was with them up through last year.  Back about 6 years ago I wanted to have wls.  I did all the tests for co-morbidities and had a couple, but my BMI was not high enough to have surgery without the 6 months of supervised diet. 

I did the diet. I had to go to meetings once a week for six months and pay $20 each time I went.  I also had to purchase their High protein low calorie food.  If I remember correctly; the cost of going and the food together for that 6 mo cost me about $2100.00. 

I really gave my all too losing weight during that time and I lost about 80 lbs in 7 mo.  I eventually put the weight back on, but was too embarrassed to return when the lbs were piling on again.  When I was over the embarrassment and ready to seek help again it was too late.  You must have wls within 2 yrs of your supervised diet for Priority Health to cover it.

I found out toward the end of this last year our company was switching Ins to BCBS and that under their plan I would qualify without the additional 6 mo diet.  So I had the DS in March.  I was charged about $27,000 for the DS and have had to pay about $1,500 of that with BCBS. 

Priority Health has their guidelines online.  You should be able to google them.

I hope this helps a little. And good luck on your wls journey. 

Thank you so much for the reply. I see that you had Dr. Kenmeeter from GHP do your DS. Did you have a good experience with him? Thanks again.

Hi there!

I, too, have Priority Health.  For several years I was looking into WLS, and unfortunately my BMI was not high enough and my only comorbidities were Hypertension and Hyperlipidemia.  Nothing else.  I had no sleep apnea, no diabetes, no heart or kidney issues...nothing.  I was very, VERY frustrated to hear that they wanted me to go through their "medial weight loss"  prior to even considering me for WLS.  I went to the inital informational meeting and even went through the medical start up, before realizing how expensive it is.

For me, I had a young son and Husband and money was the big issue.  It's expensive and we just didn't have the money.

Of course, skip ahead 5 years and a daughter later my weight was really high.  I again, talked with my PCP who wasn't the most helpful but went directly to Priorty Health.  I found out that my BMI was now high enough that they approved me for surgery WITHOUT having to do the medical weight loss portion. 

For Dr. Kemmeter, GHP charges $1,000 from PH patients prior to surgery, this does not include the cost of your food or vitamins.  I have had 3 additional bills from St. Mary's Hospital...two for anesthesia $200 and another for the surgery $300.  So plan on shelling out about $1500 in just medical bills.   We were lucky that with our flex spending account and tax return, this wasn't a huge hit to our household.

Dr. Kemmeter is AWESOME.  He is the most caring, compassionate and kind physician I have ever met.  GHP is fantastic from the exercise physiologist to the Dieticians.  You will be in excellent hands.

Dr. K was great and I felt very comfortable with him.  He has a very good track record not only with doing first time DS surgeries, but also with the very difficult revisions to DS surgeries.  He has never lost a patient.    

We are lucky to live so close to a talented surgeon.  Many people travel from out of state to have him do their surgery.  I would not hesitate recommending him and GHP to my closest friends.

 Put 2 rolls of quarters in your pockets, dress in layers, keep your shoes on. A Dr. actually told me to do this...