New here...What are my chances? Anthem

I am pretty new here.  It seems that no one can predict what the insurance companies will do.  I just want to know if I have a chance... To start some info about me: BMI 41, 27 years old MO for about 8 years now Co Morbids are Asthma, High BP, Type II Diabetes Anthem Blue Preferred Primary HMO Insurance Tried WW multiple times, a round of Xenical, joined a gym, bought a stair stepper...still only about 10 lbs from highest weight I basically would like to know if I have a decent chance of getting insurance approval for either the lap band or a lap RNY? Has anyone out there been approved under very similar cir****tances?  If so for which procedure? Also my policy has an exclusion for weight loss treatments EXCEPT the surgical treatment of morbid obesity.  Is this fairly common wording?  Does that mean that I will be covered as long as I meet Anthem's requirements?  The "customer serrvice" rep I spoke to at Anthem wasn't really willing to clarify, she just offered to send me a copy of the policy I already have... Thanks in advance for any/all help :)

On your policy is there a list of all the hoops you must jump through?  Things such as a medically supervised diet, psych eval, NUT eval, etc?

I haven't seen any specifics in my policy other than what I already mentioned, but some of the bariatric program websites in my area say that the only requirement for anthem is a pre-op consultation with a dietician. 

Hi I have Anthem too (in California.) I just got off the phone with the Customer Service department, and the guy told me that it has to be deemed medically necessary.  Medically necessary is usually defined as a BMI >40 or >35 with co-morbities AND having unsuccessfully to lose weight via traditional means (diet, excersise etc.) My reading of what you wrote as your insurance exclusions means, for example, they won't pay for Jenny Craig, but if it is deemed medically necessary to have surgery, it can be covered.  The issue is how to get to the medically necessary part, and what hoops they put you through to make that proof.  It might take months of doctor supervised weight loss, or counseling, or whatever.  Some insurance carriers will accept your testimonials (with receipts as proof) that you have done various and sundry weight loss programs already. The Anthem rep told me that they leave it up to the IPA to determine the medical necessity, which could explain why the rep you talked to wasn't able to offer you concrete advice. Good luck to you.

Hi there, I have Anthem from Ohio too and have the same exclusion you do.  I took DAYS on the phone with anthem customer service, their nurses, and eventually their attorneys because of that exclusion and another one in my policy that seemed to contradict each other.  Anyway... they WILL pay for the surgery. Your BMI is over 40, and even if it drops below 40, you have co-morbidities (asthma, high BP, diabetes). 1) Find a surgeon you like (make sure to get a referral from your PCP if you need one). 2) Document your weight loss attempts for them (this is informal, no records needed, see #5). 3) Get Nutritional counseling for your procedure (DS/LB/RNY). 4) Get a Phych evaluation. 5) Because you are are in Southern Ohio give this form to your surgeon's office.  Tell them you want them to fill out these THREE pages and ONLY these three pages and send ONLY these THREE pages to Anthem as instructed on the form.  They most likely will not know what you are talking about.  Insist!  If they send anything more Anthem's review nurses will need EVERYTHING (PAGES AND PAGES AND PAGES or records that you will have to produce). I did the above steps and I was approved about 30 minutes after Anthem's review nurse got the three pages in her hands. GOOD LUCK!

I definitely think you have a fair chance!  Get a sleep study.  If you have sleep apnea your chances greatly improve.  You also have more things than you realize.  If you would like to see the letter and appeal letter I sent that lists all sorts of stuff just let me know.    You will more than likely have to provide the last 3-5 years of medical records to verify your weight being within qualifying BMI the entire time.  Lyns