Tips for newbies who are worried about qualifying for insurance (xpost)

It seems I say these same things to many threads on this topic, so I thought I'd put them here. Vets, please feel free to chime in. These are tricks I learned In my 5.5 month appeals fight with my insurance, UHC. When I started, my BMI was 38.3. My insurance required a BMI of 40. I won, eventually. For all of the people here I have talked to, I have only heard from ONE person who has the same criteria I needed to meet. One.

1. First thing: get a copy of your insurance plan requirements in writing so you know exactly what you are up against. If you meet the requirements *in that document*, you will be approved, period. It amazes me the number of folks who have never seen this document. Contact your HR office. They should have it.

2. Get a verified height from your PCP or surgeon at the beginning of the process and use that for your BMI calculations. That is the height you want your insurance to use. Don't cheat, but make sure that you are not attempting to do your best supermodel impression, either. Height is not your friend at this point. I had a variance of 1.5 self reported inches over the years in my various medical records.

3. It is also in your best interest to weigh heavy. Again, I am not suggesting you cheat, but wear thick pants, heavy shoes, etc. that day. You get the idea...

4. Regarding denials: I had 2 of them, plus my first surgeon's insurance coordinator told me there as nothing else she could do for me, which was BS, but that is a different story. I hired an advocate (Walter Lindstrom) to get me through the process because I didn't have time with work to be able to stay on top of it. Can you self advocate and manage your own appeals? Definitely, but the path I took was the right one for me. If you do manage your own appeals, pay VERY CLOSE attention to dates and back up your assertions with facts from your medical records.

Some denial myths:

"they deny everyone the first time out". Nope. If you meet the criteria in your contract document, you are approved. Period. The catch here is that the insurance folks won't lift a finger to connect any dots, either. It's got to be crystal clear how you meet their requirements. If they can't distill the info from your charts, the likelihood you'll be denied goes up. Here is where your recent, clearly documented height and weight really become your friend.

"if you are denied, game over". NOPE. the appeals process exists for each plan. Use it. Some of it is silly (like when a plastic surgeon reviewed my file and found me ineligible) but it's there for YOU. You may have to play the game for awhile in order to get to a level of appeal where you can have your case reviewed fairly, but that level does exist.

"WLS is specifically excluded so game over". Not necessarily. My brother in law is in this situation right now and I'm trying to persuade him to FIGHT. In this case, I would go to an advocate because they can help you navigate this process. My *understanding* is that through the use of the appeals processes, you can get your case in front of an independent review board where your case will be determined based on medical necessity, not bean counter standards.

Good luck to anyone just starting out!

Laurie

(disclaimer: I'm not an advocate, an attorney, health care insurance expert, etc. I have no relationship with any advocates, other than I hired Lindstrom's to handle my case. I'm an average girl who gets frustrated with people who give up much too early, or worry about things they actually can control)

Hello there,

    Congratulations! On getting approved and sticking to it. I am also having trouble with my insurance. I heard about Lindstrom's and seen on their website their in california. Do you happen to know if you have to live in California to get their help? 

 

Thanks so much!!!!

You do not have to live in CA. I live in GA. They represented me as advocates, not attorneys because they are not admitted to the GA bar. But, that is all you need in order to pursue an appeal. Good luck in your journey!

Thanks so much! I figured out UHC is United Healthcare and that is what I too have. Mine is through Golden Rule though. Its the United Healthcare Choice Plus Network, although it is an individual plan too. Have you heard anything else about them approving people? I read people posts on this site and they talk about through their employers they have this insurance and they get approved for WLS. 

I have been overweight for over 5 years and my BMI is currently 50.5. I have 4 kids and I really want to get a WLS done. I don't know why insurances make it so difficult. My PCP did recommend it to me before also. 

I have similar coverage - choice plus, but the contract requirements are going to vary widely depending on the organization (usually an employer) that purchases the coverage. As my first coordinator told me, "oh, they accept 35 with comorbidities", I rapidly found out that when they said 40, they meant 40 and denied my 38 BMI straightaway. I have only met one other person here in the insurance discussion who has the same requirements (is through the same employer) as I have.

That said, unless WLS is specifically omitted from your plan, I have to think a BMI of 50 is looking like a fairly surefire bet for you. Get your contract documentation to be sure, though!

Good luck to you -
Laurie

Thanks so much! I am going to call the number on the back of my insurance card and ask them. I found another post on this site, which was very helpful and it was actually a list of questions that are good to ask your insurance. I saved the link and am going to ask them tomorrow. I am a bit worried because my plan is individual and not through an employer. I am a stay-at-home mom. Perhaps even if it isn't included in my plan, they might accept a letter of medical necessity. Do you think so? Also if I ask would they would send me the documentation? Sorry for asking so many questions! I am just trying to figure this whole thing out and I appreciate every bit of information that you give me. Take care!!

I will keep you posted! I have to call tomorrow though (Monday morning) because I don't think anyone would be there Sunday. 

 

I have Aetna and I am nervous about one part of the clinical bulletin...The 24 months documented weights. I have been obese my entire adult life and in 2009 my doctor advised me to lose weight. Well, I did. But an injury in 2011, caused me to be unable to workout for a while...you know the rest...Here I am today, I gained it all back plus 13 pounds! In 2011, my bmi was below 40 (37.4 to be exact). I have no comorbidities that I know of (sleep study is next week). I am currently at BMI of 43 or so. Anyone, have this issue? I am gathering weights back to 2006 to show I didn't just become obese lately. Oddly, one of the requirements is that you actually had to try to lose weight and be unsuccessful. *Sigh* This is so frustrating! Any advice is welcome!!!

I am also having surgery with Dr. Macik...I was told to get someone to bump up my 2011 weight...(its 14 pounds low, but I was also hospitalized at the time). No one will do that, seeing as its kind of insurance fraud! We can't send in for approval until 9/5/13 waiting for 90 day program to be complete.

 

Hey,
I'm not entirely clear - are you required to show history of morbid obesity, or history of failed weight loss attempts? It seems like it might be the second, and if this is the case, you may be ok, depending on the timeframe they want to see. If it is a history of morbid obesity (this was a requirement I had in my UHC claim), I pulled pages from various points in time. Don't forget to get records from places like urgent cares and your GYN if they help support your case.

Just make sure your medical chart clearly shows the ups and downs in the correct timeframe. And, based on what I have read from others, a BMI of 43 should be enough to qualify.

But, as I put in my original post, be sure to get a copy of your contract so you know specifically what you have to show.

Good luck!
Laurie

I found a missing weight from 2011 where my bmi was 40.6! They require that your morbid obesity must have persisted for the last 24 months. Basically, you need to have given up losing weight over the last 2 years. I think I'm good to go! Just had to rack my brain to figure out which doctors I saw that year.

thanks for your help Laurie!