Question:
I need help understanding the approval that isnt an approval???

Hi I am really hoping someone out there can help me... I received my insurance approval yesterday approving me for gastric bypass with Long Roux Limb up to 150 cm. It states that I am approved based upon medical necessity... Ok 1st question.... is a Gastric bypass with a long roux limb bypassing 150 cm considered distal? and Secondly there is a stipulation that after surgery if they determine there to be pre-existing condition they might decline or reduce payment.... I called my Surgeon and kinda feel like I am not going to be able to have surgery until my 1st year contract renewal date is up (which isnt until 5/04) I know this is long and confusing but I am going nuts with this anymore I feel like I simply can't take anymore let downs. Anyone know if this approval means I can have surgery? I have never been treated for morbid obesity before however I did ask 2 of my doctors to write letters of necessity for me prior to getting this new insurance.    — lillbitofsin (posted on July 17, 2003)

July 17, 2003
First, a bypass "up to" 150 cm is proximal. After 150 cm is distal - so they are approving a proximal Roux-En-Y. Second, to get the preexisting cleared up - get them to send you or identify in the policy manual what they define as pre-existing. Some go by having had the problem before you started your insurance (whether you got treated for it or not) and some go by having received evaluation or treatment for the problem within a certain time period before your insurance started. An example is that I found out I was pregnant - my husband's insurance went by "first treatment date" as opposed to the fact that my pregnancy was already in existance, at the time I got on his insurance. So, I waited until I was on his plan before seeing a doctor about being pregnant. They did a pre-existing check and saw that my OB never saw me before my effective date. There is a great loophole, however, if you did not have a gap between your current coverage and your prior coverage, the pre-existing is null/void. Lets say you changed jobs on June 10, your old insurance covered you through June 30, and your new insurance started effective July 1. There was no gap in coverage, so pre-existing is mute. There is allowed to be a gap - 62 days or less I believe, but that just means you would have to wait the number of days in your gap, not until you've been on the plan a year. If I've thoroughly confused you, feel free to email me :)
   — bethybb

July 18, 2003
The way I read the sentence from your approval is that you are approved because you meet the medical necessity they require ("approved based upon medical necessity"). Did your approval state a number of days hospitalization approved also? (This normally will be less time than the surgeon asks for, but the hospital and insurance company correspond when you are in the hospital and more days are approved once you are in the hospital.) Of course, I always recommend that you contact your insurance company for clarification and also have your surgeon's office confirm your approval. I think you're on your way! Lap RNY 7/1/03 Phys. Office Mngr.
   — Liz R.