Question:
i am gonna cry, someone please help me!

i have medical assistance ( only insurance i can get right now) its actually PA access plus.. anyways i have called them a couple times to get the complete guidelines for wls. She said I have to have prior auth.,bmi of 50% over what it should be, pre testing, mental health check, and prior diet attempts. I asked about a supervised diet... she didn't have anything on that??? I don't understand how this works!!!!! She said i have to have prior auth. before I start the other guidelines... now won't i get denied because i didn't complete the guidelines.. wtf!!! someone please please I don't understand this and my insurance company does not seem to want to answer my questions straight foward.!    — Nikki S. (posted on July 10, 2009)

July 10, 2009
Hi Nikki, Ok, your pirary care Dr. should be able to get you going. I have Medicaid/Staywell here in Fl. and I had to have 1yr of primary care Dr. visits where we were working at weightloss. That did not mean I had to lose the weight it just ment the every thirty days..and it did not aloow for me to go over the thirty days for a visit. If anything I had the visit on the 29th day. Once I was started with having my visits I checked out the DR. that did the Gastric Bypass and found the ones that took my ins. I attended that Drs. meetings and had a visit with him. Found out what ALL the pre-reqs were and then went to my primary care Dr and we did ALL the things (pre-reqs) and then I took all the info back to the Bariatric surg and we decided what type was best for me and put in the request to my ins. In about 2 weeks I had my aproval. My Bariatric Dr knew what he was doing so there was no missed steps. If your Primary care DR can provide back notes for what ever months you have been going that will work (if it is done correctly). I would be happy to explain more if you need. email me at jsnshn767@aol. I wish you well..there are a lot of hoops..but my surg was a year ago and I am down 120 lbs and wouldnt change a thing!
   — tootsie52

July 10, 2009
Yeah, don't freak out...your primary care physician will know how to coach you on this one. I live in KY and am on medical assistance, as well (Medicaid)....and I was required to have the 6 months of counseling, a psychiatric evaluation, and I'm sorry but I can't remember about the BMI. I think that, usually, the insurance companies take your whole medical scenario into consideration. For example, do you have conditions that are either being caused by your obesity or are aggravated by it. Trust me...don't freak....I highly doubt that this isn't something that you and your primary care doctor can't work out. Just go see them asap. Hang in there! Good Luck!
   — PaulaJ

July 10, 2009
The surgeon's office can help you out as well... I called my insurnace co, they said they would cover it, with the BMI of at least 40 or 35 with 2 or more conditions...... then I went to the surgeon and they gave me a list of things that I had to have done before my insurance would approve, in addition to all the pre op testing that is.... my surgeons office was very helpful... they new right off the bat what had to be done for my insurance to approve.... So with all that said... I would make sure that my first appt with the surgeon is covered... then see what the surgeons office has to say..If your surgeon has worked with this insurance before they should be able to tell you exactly what you have to do, and you MUST follow it to the T.. your insurance co will try to drag this out as long as they can.... Best of luck.....
   — wendy-s

July 11, 2009
Don't cry, we've all been there! My surgeon's office did all the work for me. I first found a surgeon reccommended to me by my primary doctor, set up a preliminary appointment and they did the rest. I never had to contact my insurance company....they did it for me. It was wonderufl, hoping you can find a program like that. Good luck! LisaRae
   — Fircrkr64

July 11, 2009
Where in PA are you? I'm in Lancaster County and and am going to Bariatric Physcians. The doctor is Dr. Alan Brader. The phone # is 717-544-2935 and the address is 2150 Harrisburg Pike, Lancaster, PA, 17604. There is a person there that deals just with medical insurance. I hope this helps.
   — Kathleen W.

July 13, 2009
I know how you feel but everyone here has gave some good advice. Get with the person at your surgeons office that deals with insurance. They are the real experts...I would give the insurance heck though I called and called and called until they got tired and decided to send me a list of the requirements. I'm in the process of the 6mo diet. Hang in there.
   — lrgsgt-o9