Insurance coverage

Hello,

I am 51 yo mom of two with a BMI of 36.7. I have wanted to have a VSG for years, but always thought my BMI was not high enough. I have so many co morbidities that I finally decided to at least consult a surgeon. I was excited (LOL) to find out that I am really only 5'5" not 5'6" like I thought since it made my BMI higher. If you are on the lighter side, you surely must understand. :)

I am just nervous about getting insurance approval. I have heard that mine (a private hospital funded insurance) is really hard to get them to cover bariatric surgery. I have several co-morbidities...diabetic on insulin, hypertension, sleep apnea, high cholesterol, stress incontinence, back pain, severe vitamin d deficiency, etc.

How did insurance approval go for you all being on the lighter side?

Thanks!

Kathy

Submit thru your Dr and expect it to be rejected. Your dr will then do a 1:1 call with an insurance rep Dr. Explaining the need with the comobordities. It will either get or approved then or 1 more rejection with your dr will appeal again, and then it will be approved. The round trip is about 60 days.

As tight as the insurance companies are, they fear the liability even more, so by the 2 or 3rd push, they cave.

My surgeon did it all and his office knew exactly what it took for each insurance. My bmi was high enough with my comorbidities  with the ones you have it should not be an issue. I imagine you will be surprised 

I started looking seriously into Bariatric surgery with a BMI of 38/39.  I was told by insurance (UHC) that I had to have a BMI over 35 and co morbidities.  I had blood pressure over 140/90 with the highest dose of a combination BP med.  I was also pre-diabetic and had sleep apnea (but not requiring a cpap).  Insurance also told me I had to have 6 months of documented supervised weight loss visits with a physician, which had to be at least a month apart but could extend out to 2 years.  I saw my primary physician for non weight loss issues in October and November, but was weighed at both and told him I was looking into bariatric surgery.  My first appointment with my surgeon was on 12/2/2015.  I had appointments in January, February and March.  My primary physician completed documentation of 4 visits:  the 2 in October and November plus my annual visits the prior 2 years.  The surgeons office had me get all available notes from my physician for those visits, and submitted them with the surgeon's documentation on 2/25.  I received insurance approval on 3/16 and had surgery on 3/28.  I also lost 34 pounds during the supervised period with the surgeon, so my BMI was actually under 35 at the time of surgery.  My surgeons office stopped "officially" documenting it once I hit 35 to make sure that there were no insurance issues, though the insurance company said it was the starting BMI that counted.  Apparently a patient was told that by one company, but then they didn't pay when the documented weight was lower than 35 at the time of surgery.  The people who do the insurance approval documentation really know all the ins and outs so you can trust that they will make it work for you.

As an aside, my BP was NORMAL in the hospital post-surgery, so the sent me home on no BP meds, though we will see where I'm at when I go for my 10 day checkup this week.  

I haven't submitted to my insurance plan yet. I did print out and save an electronic copy of my current plan and review it thoroughly. I went to the initial seminar and gave them a copy of my insurance card and they checked. I am covered and they operate out of a "Blue Distinction Center of Excellence". It was suggested in my insurance plan that for bariatric surgery I use one, so I made sure they were before attending. The surgeon's office was very confident that they would get me approved, and I have to trust that they know what they're doing, since they do it every day.

That said, I won't be the least bit surprised if I get denied initially, just because my BMI starting was only 36.8 and it seems like they have to refuse them just to see if people give up and walk away. I know that my surgeon can and will do a peer-to-peer and get it approved. 

My only fear is that, since I'm always on a diet it seems, some of my last two years of doctors appointments have my weight as well below the threshold for approval. To be honest, I have to just have faith in my surgeon and trust that they aren't leading me along knowing I'll be denied.