Great West Healthcare

Anyone have this Insurance that have had WLS and if so could you please tell me what the qualifications were? Thanks Tons, Tina

You will need 6 months of supervised visits with your doctor showing that you were on some sort of a plan.  You will need Psych Eval and Nutritional Counseling.

Would they accept just some type of proof that i have had a bmi of over 40 for well over 5 years and that I have some co morbidities as well?

Hi.  I have Great West and I called them to get their criteria for surgery. They sent this to me: Surgical treatment of morbid obesity is covered when all  the following criteria are met and documented in detail provided it is a covered benefit under the plan.        1.  BMI greater or equal to 40 OR BMI great or equal to 35 with clinically significant comorbid conditions that have failed to respond to adequate non-surgical treatment and include, but are not limited to the following:         a.  Disabling degenerative joint disease of the lower extremities worsened by obesity.         b.  Life-threatening cardiopulmonary disease (e.g.Pickwickian syndrome, sever obstructive sleep apnea not responding to conservative treatment [e.g. CPAP], obesity related cardiomyopathy)         c.  Obesity related pulmonary hypertension         d.  Obesity related cardiomyopathy         e.  Clinically significant asthma         f.  Type ll diabetes mellitus         g.  Uncontrolled hypertension despite optimal medical management      2.  18 years of age or documentation of completion of bone growth      3.  Weight management history whi*****ludes ALL of the following:         a,  Obesity duration greater than 5 years with reviews of weight management for at least the preceding 2 years         b.  Participation in a weight loss program for 6 months (within the past 2 years) with chart notes that include documentation of all of the following:            1.  A dietary program for weight loss which consists of a very-low-calorie diet program (e.g. Optifast, Medifast, Nutrisystems, Jenny Craig, Weigh****chers) whi*****ludes monthly weigh-ins and nutritional analysis            2.  At least monthly clinical encounters with a healthcare professional who does not perform weight loss surgery            3.  Increased activity/exercise regimen unless contraindicated            4.  Behavioral modification program supervised by a qualified professional to reinforce dietary therapy and increased physical activity            5.  Weight loss management histroy includes pharmacotherapy with physician prescribed weight loss drugs, or documentation of why pharmacotherapy was not tried 4.  Multi-disciplinary pre-operative evaluation that includes ALL the following:      a.  Nutritional evaluation by a licensed nutritionist, dietitian or physician      b.  Medical evaluation that addresses endocrine disorder or other cause of excessive weight gain that might be reversible without surger (e.g. medication induced weight gain, hypothyroidism) and/or physician documenation indicating that morbid obesity is without identifiable secondary causes.      c.  Psychological evaluation by a licensed mental healthcare professional that addresses the following:         1.  Absence of problems related to alcohol or substance abuse (other than caffeine/nicotine) for at least 1 year         2.  Absence of major psychotic or disabling mental health diagnoses including mania, schizophrenia         3.  Absence of compulsive or obsessive-compulsive disorder (has a high correlation with post-op failure)         4.  Eating disorder (e.g. bulimia)         5.  Likelihood of patient to comply with long-term post-operative requirements 5.  Commitment to and written schedule of planned post-operative multi-disciplinary follow-up that includes ongoing regular meetings, at least monthly for the first 6 months post-op, with psychological support/consultation, dietitian/nutritionist support/consultation and an exercise program (May be telephonic if not reasonably available to where the patient lives.) I hope this helps you out.  Good Luck!! Misty

So have you gone through all these steps with your insurance and if so what doctor supervised weight loss program did you participate in...and is the weight loss programs covered on the insurance? I won't get my insurance till about November but i'm very interested in this surgery...I have quite a few health problems that i know would be helped by this surgery and the wight loss. I had to go today to get some pretty strong medications for some pretty bad back problems...I have rods in my back from Scoliosis and now because of a car wreck I had in May the bottom of my back hurts very very bad at night when I try to sleep. Plus I had a heart attack in April of 06 that i'm on meds for..I also hurt my knees pretty bad in the same car wreck. I am going to be going to a Orthopedic doc next week hopefully...but my weight just makes everything so much worse. I think any surgery would be preferable to all this. Well thanks so much for the info it's a great help and much luck with your wight loss...grats for being on the losing side now.

I have not submitted to my insurance yet.  I am still waiting on my psych eval and nutrition appt. But I have EVERYTHING that is on the list I posted and was told by insurance that as long as everything is turned in then I have nothing to worry about. As for the supervised diet, I have a 6 month one from 2006 that I am using.  But my insurance does cover anything to help you lose weight as long as it's medically necessary.  For your supervised diet, you want to make sure that your PCP documents everything well.  Such as amount of weight loss, discussions of your diet, exercise, and you must try a weight loss drug I had phentermine.  I have read that Great West is one of the easiest to get approval from, so I am hoping this is true.

I really don't think with my heart history that diet drugs are going to be possible for me...I really have to watch what drugs I take because it might interact with my heart meds...I am currently taking Vytorin, Plavix, Topril and asperin and now percocets for my back pain...I have heard a lot of diet drugs arent real good for your heart...have you heard anything about this?

As long as there is a valid reason for no drugs, then it's ok not to have them.  Your pcp will just have to put that in the notes. I'm not sure about the drugs not good for the heart.  IT's very possible though.  I know I had to wait a week once for my phentermine because my BP was high and I have NEVER had high BP.  So I know it was the phentermine.

Yea I think with my history I'm almost positive my doc won't want me on those type of drugs...thats the same reason I have never tried them before...but I think anything else I won't have a problem with.  Just seems like to me the insurance company could save a lot of money and just ok the sugery instead of paying so much extra money for the 6 months of diet...because they will be paying for all the 6 months of diet that we go through and then surgery instead of just paying for surgery...doesn't make a lot of sense. You would think they would figure out if we have not lost weight in more than 5 years we arent going to without some drastic measures. Oh well what can you do. Thanks again.