a little frustrated, and confused - suggestions?

hello.  I was told quite a while ago that I have PCOS.

I am really overweight.  I have been overweight for quite some time (and am tired of it), I think since I was in my early 20's.  My doctor told me that I am about 80lbs overweight now.  I am fairly active for an overweight person, and probably like everyone else, I have tried every diet known on earth and despite not cheating, I have had no positive results.  My obgyn(who did tests and diagnosed me with pcos) has told me that I need to have wls or I will get diabetes (he did sugar tests). 

To make a long story short, there are 2 woman at work that have had great success with wls (i don't know if they had pcos)  and they have been telling me all the positive aspects of wls.  After considering a lot of this, and listening to them, I finally decided I want to do it.

Here's where the frustration kicks in.. my insurance.  I have finally psyched myself up to get started with this process, then my insurance tells me that they wont pay for me to have the surgery unless I do a Dr. monitored weight loss program for 6-9 months to prove I cant lose weight.  Why am I frustrated?  Well, my obgyn already told me that I cannot lose weight, nor will I without surgery.  I am on a budget, and the insurance wants me to pay to be on a an expensive diet that will do nothing for me.  Did you all have to do the same thing?  Is it just my stupid insurance? (its a very costly PPO program btw)  I was psyched to do this, and was shot down.  I am not trying to get pregnant or anything.. I just want to lose weight.

any comments are appreciated.

 Hi,
I had to go through 6 monthly weigh ins and keep and activity and food log with my primary doctor before I could do my education day with my WL surgeon and my Psych eval. The whole process took about a year and a half but even though it was frustrating at times, it was so worth it in the end and I would do it all again if I had to. Hope this helps you decide if it's for you. Just remember that this surgery is not an easy fix for weight loss. It is just a tool and you will need to work at it the rest of your life to maintain the weight loss.

If your insurance has a clause in it's coverage stating they cover any form of weight loss surgery at all you have a fighting chance for approval. Here is what you may want to try. I pulled this information from the internet back when I was helping my mother seek approval from her insurance company. It was not an easy process and was frustrating at times but it did end in her insurance covering the procedure.

Instructions (from http://www.ehow.com/how_2039640_insurance-gastric-bypass.htm l)

Step 1 - Discuss with your surgeon the financial aspects of gastric bypass surgery and the amount needed post-operation. This would depend on the complexity level of the surgery.

Step 2 - Assess your financial requirements. The key point is the amount you can claim from the insurance company and the money that you will have to shell from your pocket before, during and after the operation.

Step 3 - Go online and shop for the best quotes. Several insurance agents can help you buy the right kind of insurance. Take advice from reliable insurance companies or agents.

Step 4 - Compare ratings of the company. Insurance companies are rated by several agencies such as S&P and Moody's. Choose a company with higher rating and the ones which offer better service on claim processing.

Step 5 - Ask the insurance agent or read the clauses carefully in the policy. Find out whether the coverage of gastric bypass surgery is as per your requirements.

Step 6 - Provide a referral letter from your primary physician and the surgeon when necessary

Step 7 - Maintain accurate health records and receipts before and after the surgery. They may be needed for payment the insurance claim.

Step 8 - Ensure that your surgeon has all the required documents ready for the insurance company in your case.

Step 9 - Contact the insurance company periodically before and after the surgery to know about the progress of your claim.

Step 10 - Find out the payment mode of insurance claim. Ask your insurance agent when and how the payment would be made to settle the surgeon's bill.


Or you can try going the route of the appeals process which I have heard is also frustrating but very worth it in many cases. You have the right to appeal to your insurance company with the help of your primary care physician or surgeon. You will need to look up the appeals process for your insurance carrier and make sure you follow it to the letter. You can probably get your doctor's office to assist, especially if you are dealing with a bariatric surgeon. They are sometimes more versed in the proper way to appeal to insurance companies (those they accept payment from) and garner a positive outcome for you as their patient.

Even though you have not been keeping logs of every attempt you have made to lose weight your weight loss efforts may be documented well enough in your doctor's office visit notes over the years that you may not need to have the added frustration and expense of a costly diet program. The key is talking to your past caregivers to see if they will write letters of recommendation for you based on your medical history (so long as they documented any weight loss related conversations you had in your visits). The more the merrier in this case. I would recommend obtaining a copy of your medical records from your doctors so you can review them yourself and read through the doctor's office visit notes. This can save you time in the long run. You won't be left waiting weeks for the doctor to get around to reviewing your chart and then waiting some more while the office staff drafts something he is willing to sign.

I hope this helps you. I know it's a lot of information and I know insurance companies can be a pain, but hang in there and give it your all and  you have a good chance of being approved for surgery. Best of luck to you.

I work with bariatric patients in Florida and from what I have seen there are very few insurance companies that I can name that do not require a documented weight loss trial. Some bariatric surgeons have a prefered doc who does the weight loss trial. If you know who you want to do your wls then call there office and ask if they have recommendations. I say this because insurance companies are very particular and a lot of PCP's are not familiar with the requirements and people get denied if everything required isn't documented. Also some insurances require documentation to show that you have been overweight for a certain number of years. So get in writing from your company what there specific requirements are. A good surgeons office will be very familiar with the requirements of differnet companies. So try to figure out which one you want to use who is covered by your ins. And see how they can help u expedite this process.

I work with bariatric patients in Florida and from what I have seen there are very few insurance companies that I can name that do not require a documented weight loss trial. Some bariatric surgeons have a prefered doc who does the weight loss trial. If you know who you want to do your wls then call there office and ask if they have recommendations. I say this because insurance companies are very particular and a lot of PCP's are not familiar with the requirements and people get denied if everything required isn't documented. Also some insurances require documentation to show that you have been overweight for a certain number of years. So get in writing from your company what there specific requirements are. A good surgeons office will be very familiar with the requirements of differnet companies. So try to figure out which one you want to use who is covered by your ins. And see how they can help u expedite this process.

 I was not required to do a supervised diet because I have comorbidity.  I am not sure how many you have to have, but I have 4 big ones and a few minor ones.  I was prepared to have to do the 6 month diet, as that is what I have heard everyone doing.  I'm not sure what your health situation is, but if you have several comorbids, that might be a reason to appeal.