NJ Direct (Horizon)

Anyone have this insurance.  My BMI is >35 but under 40.  I have some comorbidities not sure what or how many are needed.  Have plenty of problems due to the weight.  I have arthritis and leg pain, back pain, acid reflux, depression/anxiety,  and more.  I read somewhere that the comorbidties have to be life threatening.  Is that true?  Does that mean at some time in the future or does it mean fairly soon if my weight remains untreated? 

I have Nj direct all you basically need is 6months dietsregular testing from docs and it have to be medically necessary.How far under 35 are you that may be a factor .If you have all these issues you can apply and see what happens if you get denied you can appeal but, all in all it wasn't that bad i was submitted and approved fairly easy.nowadays insurance companies rather pay for the surgery than medical problems....wish you luck on weight loss journey 

Hi,

Thanks for the reply.  I'm not sure what you mean by six months diets.  Will they make me go on a useless medically supervised diet for 6 months?  I was on Weigh****chers about a year or so ago  about 7 months, lost 46 lbs and gained back 55+.  I joined again about 2 months ago,Weigh****chers on line.  No doc's involved, I'm still gianing weight.

What do you mean by regular testing by docs?  I haven't consulted a doctor for my weight in years.  Mainly, because it doesn't work.  My first doc assisted weight loss effort was in 1970 (39 years ago) where I lost 75 lbs. with diet pills.  That doctor was in his 60's at that time.  I doubt that he is still alive and those records are not available. I've gained and lost that 75+ lbs now so many times now that I can't even count them. I went to Glenbeigh in Tampa for an eating disorder in 1988 or 1989.  I'm not sure that place even exists any more and I don't remember what insurance company that was, maybe Aetna.  I have no records of any of that.  Weigh****chers, South Beach, .... I have a 40 year history of failed diets but the documentation on that is skimpy at best.

I was treated for oestoarthris (bad knees) about 2 or 3 years and was told the weight was a big problem.  There is a record of that.  At that time my BMI was about  >35 (not exactly sure how much over)   Is any of this info useful to the ins co or is the standard much higher and hrder to prove?  Never thought I'd have to fight to prove I'm dangerously obese.

Some insurance companies require 6 months Doctor Supervised diet plan. Even if you loose weight on the diet, you can have the operation. They just want to make sure you did it. It’s stupid I know. Weigh****chers may be ok, but you need to have records you went for at least 6 months straight. Cancel checks would help, or if the WW you went too has a record of you then that can help too.

 

Most insurance companies will want to see “your medical history" to see if WLS is really for you - especially if your BMI is under 40. You may need to have an “official record" of what your additional co-morbidities are. Saying “I can’t sleep right" doesn’t mean a thing to insurance companies. Having tests and documentation does.

 

Again, not saying your CAN’T have the operation without these things - but it will make it easier.

 

Remember, insurance companies don’t want to pay unless they have too. Many folks look at WLS as an “easy way out" - and it’s not. It’s a drastic change and takes a lot of work. If you’re looking for the easy solution - WLS isn’t for you.

 

Meet with a Weight Loss Surgeon to discuss what needs to be done. They will give you better information.

Oh by the way - I had Horizon BCBS and didn't pay a dime (ok, some things I had to pay "out of pocket" - but it was less than $1,000 total).

Sorry What I mean by 6 month diet is that you have to see your pcp. and he must document your weight for 6 months before insurance submital. So say if you start now every month he has to write down your weight and say what your doing about it ..like Oh doc I'm going to weigh****cher sand i cut back on this and that. but the doctor has to write it. I know a pain but it goes by pretty fast.


Now when I say regular testing I mean. Gastronteroligist upper gi scope, cardiologist heart ultrasound and stress test, pulmonary doctor for breathing test and sleep test. and a gallbladder and heart ultrasound...these are the regular test you need to take to get submitted for approval for wls. also a psyc evaluation.

edited to add 5yr weight history

Hi....I don't have the insurance you have but went to my surgeon's New Patient Seminar last night....if you have a BMI of 35 you will also need to have comorbidities....if you BMI is 40 or above that is good enough to qualify for surgery. Now whether your insurance calls for a Nutritionist Eval or Psych Eval or 6 month supervised diet, which mine needed all 3 I have Cigna, that will need to be discussed with the Surgeon's insurance specialist.

Here is the link to the group I have chosen...I'm having Dr. Abkin. This group is one of the top groups in NJ and quite possibly the country. There website will give you lots of great information that may be available here..just not sure where.
http://advancedlaparoscopicsurgeons.com/

As far as life threatening...Obesity is life threatening. These insurance companies need to get up with the times and realize Obesity is a disease in itself and shouldn't require other problems in order to be qualified.

Good luck on your journey...you've come to a great place for support and information.

Kimi

I have that insurance and had to do 6 months medically supervised weight loss with a doctor or
the nutritionist from the surgical group.  (I chose my dr.)  Also psyche eval and nutritional counseling - one time each.

Go to that website mentioned about five blogs down - the advanced laparoscopic one and
attend a seminar.  You can probably also call that office and ask what you need to do under your
specific insurance. 

I had my lap done in Dec 08 - at that time another lady who was operated on same day as me
told me she was able to use six months of WW records - I dont know if they were her checks or
WW records.  It had to have taken place within the year.

It is a lot of paperwork and a lot of running around, no doubt.

Good luck,

kb

The first thing you need to do is go to a seminar and make an appointment to a bariatric surgeon who accepts your insurance. He will tell you your insurance requirements and will start documenting your weight for six months don't waste time. Start now the 6  months will fly by.

I have this insurance- NJ Direct 10 from Horizon and my surgeon is Dr. Abkin

I have completed all of my evals and have been cleared by all involved.  My PCP is currently writting the letter of medical necessity and copying her 6 months of notes for submission to the insurance company.

My question is this.  How long from the time the materials are submitted to Horizon, can I expect an approval?  Is my date to be scheduled prior to that approval and then given the green light upon receipt?

how long and how does it work from here?

Of course everyone is different, but for me it was less then 2 weeks.

ADVICE: Call your insurance company every 3 - 4 days and see where it stands. If approved, get the approval number and call the office with it. I did that. And I knew before the office knew I was approved.

Also, remember the folks who answer the phone is the "first line" and may not have all the information. After the 1st week ask to speak to a supervisor. BE POLITE - but make sure you talk to someone who knows what is going on. They can also advise you if there is a "hold-up" and what you can do to correct it.

Good Luck !!