Questions for my PCP

Hello LGBT community!


I did not know that this forum existed until just the other day, and hey.... its great!

Any whose,


Today I visit with my primary care physician and will talk with him about getting this ball rolling. I found out last week that my new insurance does cover gastric bypass surgery, and after many years decided to give it a go.

You can read my story here.

Well, when I called United Health care (does anyone else have them?) they said they cover gastric bypass surgery with a BMI of 40 or greater and five year history of obesity. Over the course of the past five years I've had intermittent insurance (some years with and some without) and told them I could not verify five consecutive years of coverage. But I did tell the councilor that I have kept the same primary care doctor that I had five years ago, and that he could document the weight for the time I've seen him, and the councilor said that should be fine.

I asked if there was anything else needed by the insurer to document and they said no, so I am guessing this also means no six month diet plan accounted for?

But the issue is my BMI is 37.7. I learned from other sources that most insurances do cover gastric bypass with a bmi of 35 or greater with a major commodities  whi*****ludes Diabetes .... which I have had for five years now with Neuropathy  (numbness and sharp pains in my hands and feet).

When I had asked the insurence company if they will cover me with a bmi of 37 with a comorbidities she would not answer me, rather told me to have my doctor to send in a claim form. I dont know what this means .... why wouldn't she answer me? So this make me nervous that they would not cover me. Has anyone else had this occur?

Ok,

So I am going to speak with my primary care physician to see if I also have sleep apnea and maybe acid reflux (I do think I have that, :(  ) and to see if he can get on board with me and write a statement about my weight history.
 
Might anyone else have any other questions I may ask my pcp about to get the ball rolling? Should I ask him to place me on a formal diet plan so that it is documented now?


*waves*

David

Good Luck David,

I was a self pay VSG because I was not willing to wait the 5-7 years to have it done and paid for here in Canada.

I am sure people will give you their take on insurance.

Cheers....Jane

Nice to meet you Jane!

I love New Scotland!!! 

Hi David, Welcome. I'm glad you found us. We rock!!! :) 

I had my GBP done through Kaiser so I don't have the experience with insurance from that point of view.

I have worked in insurance in the past and now work in healthcare and I can tell you that the person you spoke with was not allowed to answer your question. It is a determination that will be made based on documentation your PCP provides to the company and will be made above her head. So don't think that her silence as denial. It is just the beginning of dealing with the insurance.

In my experience you have sufficient comorbidities with a BMI of nearly 38 to qualify. You may have to fight for it but I have a good feeling about it on your behalf. *g* Diabetes along with the inability to permanently lose the excess weight should be sufficient, especially if you are insulin dependent.

Keep us up to date on your journey. Even if we don't have the answers, you may be helping someone else who is reading. We are all here to help each other.

Again, glad you're here and good luck!!! 

Welcome David!

Don't get worried...your PCP should refer you to a surgeon.  The surgeon and his staff are well aware of what the insurance company will require and will make sure you complete all appropriate tests (EDG, Sleep Test, Cardiac, etc.).  They will also know if you have to complete six months with the nutritionists and may get you setup with that.  My nut works directly with my surgeon.  Also, they will deal with the insurance company.  You have already confirmed that your insurance company covers it...now it's time to see what has to be done to get the approval.   I never spoke with my insurance company after they confirmed that they cover gastric bypass.

I started my process with my PCP in November 2007 with my annual check-up to make sure he would support me...and he was more than willing even though I didn't have any co-morbidities (even though my BMI was 44.5).  The only thing I needed from my primary was a letter of medical necessity for the insurance company.  Everything else was done at the direction of the surgeon and his staff.  I finally completed my six months with the nut and all of my tests in early October 2008 and had surgery in November.

Good luck and please keep up posted!!

Brid 

Hey, David,

I had a BMI of over 56, so, even though I didn't have co-morbidities (yet) I was approved no problem.  I do recall something on my policy (through Blue Cross/Blue Shield of Alabama) that the norm for approval was a BMI of 40, but those between 35 and 39.9 could be approved with documented CM's.  A lot of insurance companies do.  But I don't really know the details as I didn't have to worry about it.  What my surgeon did do, and he did this for everyone, was he sent a request in at the very beginning (knowing it would be turned down) that way, in the denial letter, they would outline everything we needed and there would be no surprises.  I'm not sure if this is standard practice among surgeons.

Would never hurt to start a diet plan, anyway, and get it documented.  What's the worst that could happen?

A little OT, but how's life in Norfolk?  I spent my teen years in the Salem area of Virginia Beach while my dad was stationed at NorVa, from 1985-1990.  I loved it there!  I went back a few times in the past few years, and it's gotten even better.  And I love the handle.  Drachen Fire was a great ride at a great theme park.  Alas, I will only be able ever to ride it on YouTube as they dismantled the damn thing before I ever got to ride it!

Hope the info helped, but if it doesn't, don't worry.  There are a lot of people here who actually know what they're talking about.  I'm going to go and walk on the beach and post more pictures of it so everyone can tell me how much they hate me.  Sige na!

Cheers,

Chris

Congrats on your decision to take charge of your life. I can speak about Aetna and their weight loss surgery qualification. Like yours, it is 40 bmi or higher or 35 bmi if you have 2 comorbidities like diabetes, heart disease, etc... I would call your insurance and ask for their "Clinical Bulletin on Weight Loss Surgery". Aetna had one that itemized everything about the surgery and qualification. I suspect an insured of that size has a similar document.

Now for your PCP. Ask your surgeon's office for a letter detailing  what your insurer needs for approval. Mine gave me this and it helped my doctor. It told him he had to record office visit notes on each visit that involved counseling me on diet and exercise. He also gave them my 12 year of weight history and other things I can't recall right now. I know most surgeons have person who handles insurance. They are the people *****ally know what is needed.

God Luck!
Tom

Thanks everyone for your encouragements, and especially many of the clarifications. 


I went to my pcp on Friday for lab work and to touch base, and asked him about gastric bypass.

Well, get this... he goes on to lecture me that the surgery is for people who are 100 lbs or over who meet a certain bmi and basically tries to dissuade me from that consideration. I then blurted out .... "but I am [overweight] and have been since I've been coming to you in 2005! "  It was as though he hadn't looked at my charts or even at me! 

So I am thinking my doc may not be as in touch as I thought. In the end he didn't do a formal referral per se, but did say I was free to consult with the surgeons at Sentara Norfolk General. So I enrolled to sit in on a class with that this upcoming week. During the class, we will meet with surgeons who will answer our questions.... I understand that their offices will coordinate with the insurances and help me get everything together for them.

Incidentally, the doctor is also giving me medicine for neuropathy in my hands and feet, as well as (now) chronic heartburn. Does this mean I formally have neuropathy and acid reflux? He didn't have me see any specialist, just prescribed me the drugs. 


Again,  Thank you for your perspectives!  In your experience, do you think that insurance companies will budge if you do not have a complete well documented 5 year history due to laps in insurance coverage?


________________


@ Chris: Small world this is!

Though a child of the Smokey Mountains (from East Knoxville of Welsh extraction), my father was Navy and we lived in Subic Bay between 76 and 81 before moving to Virginia Beach in 82.... three years before you! lol. Allot of my early memories are of the Philippines

In Subic Bay we had a Filipino nanny (Nina), and learned some Tagalog but have long since forgotten it. My sister was born there, and because of her habit of running around naked she gained the name "bomba"  (though I don't remember if that means naked or not)  lol.  I remember going to Nina's home in Olongapo for some weekends and playing with her nephews and nieces. I am looking now at some family pics of the place as I write! As a kid, the beetles there scared the crap out of me! They were huge! Good times.

Anywho, you were in Virginia Beach between 85 and 90? During those years I was at Rosemont Elementry I think.... maybe KempsvilleJunior. Eventually my teen age years were spent growing up on Chick's Beach and going to Cox HS, do you know of them?

Yeah, I like it here in Norfolk... especially bohemian Ghent. Kinda like Georgetown meets the South! lol. We are building a light rail system between ODU and the Virginia Beach Ocean Front... so that will be cool.

Yesser! Drachenfire is inspired from Busch Gardens' DrachenFire rollercoster. Being of Welsh heritage... the dragon is the emblem of the Welsh and it always seemed to appeal to me.  So... I adopted it as my handle most everywhere I go.

It is a small world, isn't it?  You arrived in Subic Bay the same year we left.  I was only one at the time.  We each had our own nannies as well, but I'm too young to remember them.  I don't remember anything at all about the Philippines, so when I moved here last year, it was like being here for the first time.  And the bugs here do suck.  I've been caught screaming like a girl over a fighting spider that jumped out at me and a cetipede I found crawling under my desk chair.

In Virginia Beach, I went to White Oaks Elementary before Kemps Landing my 7th grade year.  Then I went to Salem Junior High School the year it opened for my 8th and 9th grade years before my dad retired and we moved to Huntsville, Alabama.  I remember FW Cox.  The rich kids' school up in the northern part of the city, whose football team was just fodder for First Colonial and (my sister's alma mater) Green Run.  Those were some good years.  We used to go to Damn Neck beach (with the marines) and I remember the bathing houses on the beach.  The marines there definitely were not shy.  I think I became an adult in those bathing houses...    We hung out on the oceanfront or at Lynnhaven Mall, back when Mother's Records and Aladdin's Castle were the most popular places to go.  God, how old am I now?

I can't believe the beach allowed the light rail into their hallowed corporate limits...  I know they were against it for a long time.  I'm glad they're moving ahead with it.  I got to see the Ghent for the first time as an out guy a few years ago, I never realized that it was actually Norfolk's "gay neighborhood," but I fell in love with it.  I missed the proximity of Busch Gardens and King's Dominion (I'm a huge coaster lover) and all of the water, but not the nightmarish traffic.

Well, good to get to know you.  If I run into your Nina here, or a couple of those obnoxiously huge beetles that may remember you, I'll let you know.

Cheers,

Chris

Hi David,

Who is your insurance company?

I have Aetna like Tom and the process was really quite simple.

The first time I saw the surgeon was in the end of Dec and I was approved by April.

My BMI was 40.9 in Dec ( it has gone up since due to my compulsive eating while waiting approval).

I had sleep apnea which had previously been documented and that was enough for Aetna.

As i told you before, the dr's office did everything. They told me what tests were needed, what kind of documentation they needed from my PCP (which was only 2 years of weight and diet info by the way and not 5).

I still am amazed at how easy the process was.

Now  I need to get clearance from my PCP tomorrow so I am good to go Monday. I hope he gives it to me with this stupid cold I got over the weekend.

I hope the seminar is informative and that you get all of your questions answered but if you don't there is a lot of really informed people on here you can turn to for advice.

Good luck!
Kevin