WLS Approval through Anthem (COVA CARE)

Has anyone used COVA Care for their insurance provider?  I have yet to go to a seminar (schedule Jan 9, 2012), but I'm sure Lap-Band is the right surgery for me.  I just turned 25 this month and dieting was actually one of my first memories as a child.  I have always been active (basketball through high school, softball through college), but theres just something missing.  I lose 40 and put back on 60 within a 6 month period.. I'm tired of yo-yoing.

My question is:

If you used Anthem, even if you had a high BMI (mines 43), do you still have to take the 12 month evaluation.  I was on WW twice in a 3 year period and did not succeed either time.  Do they take any of these things into consideration?  12 months just seems so discouraging.. I already feel terrible, depressed, unmotivated.  I dont know if I can take 12 more months of this. I've heard they are quick to approve, but is this always after the 12 month waiting period?

Your  Anthem WLS coverage will depend on the terms of your particular policy. Another person with Anthem might have a completely different policy. I have Anthem BC/BS and didn't have to do a 12-month evaluation. So before you get even more discouraged, call the customer service folks at Anthem and ask for the details for your particular policy. Generally speaking, insurance companies do not make exceptions to policy exclusions or requirements - their rules are the rules you have to follow. You could hire an attorney or an advocate (such as the Lindstrom Obesity Advocate advertised here on OH) to challenge Anthem, but that could end up taking 12 months and you might still be denied. 

I completely understand about feeling terrible, depressed, and unmotivated, but I have to tell you straight out that WLS will not work well for an unmotivated patient. Weight loss takes a lot of determination, persistence, and hard work, with or without WLS. If you have to do the 12-month thing, you can use that time to get yourself prepared and psyched up for the surgery and all the work and changes that will follow.

Good luck!

 

Thanks for the info. As far as the unmotivated goes.. It's because I've tried everything I can with everything I've had only to end up heavier. I'm not a lazy person who thinks if I get this surgery the weights gonna fall off of me while I watch tv and sit on the computer.

I've gotten so big that being active has become miserable. I HATE that. I've been active my entire life and I just want that back. I have no unrealistic goals.. If I can get down to 165-175 and a size 10-12 I'd be perfectly happy.

I know you don't live in California, but for those that do...their Ins. companies cannot force their insured go through this waiting period.

 

I am quoting this information from a very reliable and informative person.

 

http://www.asmbs.org/Newsite07/resources/ASMBS%20Position%20 Statement%20on%20Preoperative%20Supervised%20Weight%20Loss%2 0Requirements.pdf PRE-OPS: YOU CAN FIGHT YOUR INSURANCE COMPANY'S REQUIREMENTS FOR PRE-OP WEIGHT LOSS PROGRAMS! Summary and Recommendations 1. There are no Class I studies or evidence-based reports that document the benefits of, or the need for, a 6 to 12 month pre-operative dietary weight loss program before bariatric surgery. The current evidence supporting preoperative weight loss involves physician-mandated weight loss to improve surgical risk or to evaluate patient adherence. Although many believe there may be benefits to acute preoperative weight loss in the weeks before bariatric surgery, the available Class II-IV data regarding acute weight loss prior to bariatric surgery are indeterminate and provide conflicting results leading to no clear consensus at this time. Preoperative weight loss that is recommended by the surgeon and/or the multi-disciplinary bariatric treatment team due to an individual patient’s needs may have value for the purposes of improving surgical risk or evaluating patient adherence, but is supported only by low-level evidence in the literature at the present time. 2. One effect of mandated preoperative weight management prior to bariatric surgery is attrition of patients from bariatric surgery programs. This barrier to care is likely related to patient inconvenience, frustration, healthcare costs and lost income due to the requirement for repeated physician visits that are not covered by health insurance. It is the position of the ASMBS that the requirement for documentation of prolonged preoperative diet efforts before health insurance carrier approval of bariatric surgery services is inappropriate, capricious, and counter-productive given the complete absence of a reasonable level of medical evidence to support this practice. Policies such as these that delay, impede or otherwise interfere with life-saving and cost-effective treatment, as have been proven to be true for bariatric surgery to treat morbid obesity, are unacceptable without supporting evidence. Individual surgeons and programs should be free to recommend preoperative weight loss based on the specific needs and cir****tances of the patient.

I wonder what would happen if everyone complained to their state insurance commission and demanded that the governmental regulatory agency tasked with monitoring and regulating the behavior of insurance companies must make them STOP torturing their patients, delaying and in many cases thereby effectively denying them critically needed medical care, by imposing onerous, arbitrary and capricious requirements for which there is NO EVIDENCE-BASED MEDCIAL SUPPORT that amount to a poll tax for morbidly obese patients trying to access the ONLY treatment that works. The insurance regulators should DO THEIR JOBS and order the insurance companies to remove these barriers to access to medical care from their policies.   End of quote.  

 

I agree with Jean, it does not matter WHICH insurance you have, it depends on what your EMPLOYER covers. You need to call your insurance company and ask them if Bariatric surgery is covered and if  there is any out of pocket costs you have to pay.

If they do cover weight loss surgery some have rules to follow like a 6 month diet program and some do not, it greatly depends on if your employer actually covers it and then if they do, it depends on the guidelines.

I am actually in the process myself, through cova care and I know that there is no waiver for the 12 month weight loss program, I see my surgeon on jan 28th to get the ball rolling. I to am in va.

I am currently in process, in Va. and my year is up 5-18. 

If you work for the state, and am frustrated that their FAQ is disabled on the website, that is my fault.  The only waiver you can get for "time served" of the 12 month program, is if you have just transferred insurances, and were in the same type of program in your previous ins.  Does that make sense?  You can try to get a medical emergency waiver, but my life coach said in her experience, they were few and far between. 

The 12 months will go fast.  You will talk w/ your life coach 2x a month, and 2 of those months you will have group calls, usually for 3 weeks in a row (no life coach calls these months).

Do not give up!  The state put this program in place because they don't want to pay for it!  They WANT people to give up! 

Hi Abbyluwho!

I am beginning the process now through cova care . I am curious if you followed through with the bariatric surgery after you finished the 12 month program. Did you find the program helpful to either lose weight and prepare yourself for the surgery? If you had the surgery, would you do it again?

My insurance was COVA Care.  Although I had done WW before, I was required to do the 12 months weight management prior to surgery.  At first I was discouraged but later was appreciative of the time it gave me to change habits, prepare for the procedure, and buy the supplies I would need later (bariatric vitamins, supplements, shakes, etc.). I followed all the guidelines, kept all of my appointments (and receipts), and did not miss any of my coaching calls. Read your certificate of coverage for details on what and how is covered. The approval process after I was done with the pre-requirements was fast and easy.  It is important to follow all the steps, keep records, and be patience.  Good luck with your surgery.