Question:
I'm still confused! Is it the surgeon or the insurance company?

Who decides what procedures are required before approval for surgery? I've read so many messages about psych exams, upper gi series, pre-op diets etc. etc. When I spoke to my insur. carrier I was told that my policy allowed for bariatric surgery when deemed medically necessary, including the lap band. However,it seems like there must be more to it than just getting my PCP or Surgeon to say that I need it. My BMI is 37 and my only co-mordid conditions are, degenerative disc, depression, heavy/irregular mentrual bleeding and general joint aches and pains that come with carrying around extra weight. Anyone have any insight? Thanks!    — [Deactivated Member] (posted on September 15, 2005)

September 15, 2005
Hi. Let me try to answer your question by telling you what happened with me: My insurance needed a few things, like my weight history, a letter from my PCP saying that I need WLS, a diet attempts history, and a psych eval. Did all that, and after a about 1.5 years, I got approval. (That was paritally my fault... I didn't stay 'on it' with the calling and everything) Okay, so got my approval. Now that I have that, my surgeon requires very extensive pre-op tests. I did that last week. Those are paid for by my insurance, because I was approved for the WLS, and also for any treatments related to it that my surgeon would require. So, your surgeon may want a whole bunch of testing done, or he may not need many tests at all. Right now, your main goal is to find a surgeon, and get insurance approval. Usually their office can help you with that. Also, if you have ever went to your PCP about any of your comorbs, have him/her write a letter about your problems, and how WLS would help those. Any questions feel free to drop me a line through my profile! Amanda PS) Sorry for any spelling errors... I'm just going to send this without spellchecking... I'm tired! =)
   — AmandaLeigh =)

September 15, 2005
Howdy, This is how it worked with me.My family dr. had to give me a referral to a weight loss surgeon. After my consulation he gave me a list of things I needed to get done for him and for the insurance company.The Insurance company wanted a letter from my dr. and my surgeon saying that weight loss surgery was medically necesary, six months diest documentation, phyc eval. and any comorbs I had due to my weight from my Family physician. My surgeon wanted test done on my heart, lungs, sleap apnea things like that to make sure I was fit for surgery. So to answer your questiong Both the insurance and your surgeion will ask for tests. Your WLS Sister Conijo Michalko 375/160/140
   — Jo_Michalko

September 15, 2005
I called my insurance co. first to see if the surgery was covered and then they said I needed a letter from my PCP , a psych evaluation and a diet history after that the surgeons office took care of everything, all the other tests sleep apnea, gallbladder ultrasound, venus doppler (leg vein check) were all ordered by surgeon. Good Luck I started my journey in May and finally have a date Sept.29th it's a long process but well worth it Take Care Pamela Tweedie
   — sunnie

September 15, 2005
Hi! My BMI is 39 and I have a family history of heart attack, stroke and cancer. My co-morbids are reflux, asthma, joint pain, feet problems and depression. I started my journey in May 2005 and my surgery is scheduled for October 5. The only thing I was required to do was meet with my family physician to get approval, then meet with the WLS. After I received approval and a date I had to schedule to meet with the anesthesiologist and the nutritionist and have a physical from my family doctor within 7 days of my surgery. That's it--no sleep apnea and all the other testing people talk about. Best wishes to you! I'm counting down the days to a healthier me!!! I wish the same for you!!!! Lezlie :)
   — Lezlie

September 15, 2005
Hi, First offs high enough to warrant this surgery without any other problems. Second, it is pretty much up to the Insurance what type of surgery you have. Some don't cover the band, so that leaves only the RNY. Everyone has to do certain testings prior to having surgery (that is for your own good) and if you don't have any done I would change Dr. right away. The phych eval is important to find out if you are able to handle this procedure as it is life treatning to have & also changes your life drastically. It is not a cure & you have to work at getting & keeping the weight off just like before. This is not an easy way out for being fat, it is darn hard work. So with that, if you still decide to go with this surgery. I don't think you will ever regret it & you will be on the road to a healthier you than you have ever had in your lifetime. Good luck & hope you get what you set out for. Hope this helps a little. by the way where do you live? & who will your Dr. be? Marilyn, the Bearlady
   — Marilyn C.

September 16, 2005
Your insurance company usually has some things you need to do to prove that the procedure is medically necessary. I had to have it documented that I tried to lose the weight by dieting (more!) for an additional six months. I also had to have a psychiatrist, exercise physiologist, and dietician sign off on it. I had to have my comorbidities validated by going to a cardiologist for my high blood pressure, a pulmonary specialist for my sleep apnea, and get an endoscopy and a colonoscopy. I also had to have my PCP send a letter to the insurance company. some insurance companies do not require you to jump through aas many hoops, I hear. Your best bet is to call or visit your insurance company online to get an exact idea of what to do. Your surgeon's office may also have some information.
   — Novashannon

September 16, 2005
Hi. I noticed you have a PPO which means that you won't need a referral from your PCP. All you really need to do is find a surgeon, one that is in-network, and then make an appointment. The surgeons office will usually take over after that but it's mainly the surgeon's office that will set you up with all the tests, exams and consulations with the nutrionist etc. Please please verify that these people are all in-network because you don't want to be caught off guard. Oh, also make sure you ask your surgeons office if they're are any additional fees that are not covered by insurance. I'm sure they will have some. Good luck to you!
   — J. Bee