Question:
Who do I talk to in order to find out specific requirements for surgery?

I have seen several posts regarding getting approval during your physician supervised diet. I'm currently on a program with my physician, having monthly appointments and weigh ins. However, I am not pursuing insurance approval, etc. because I have no idea what the requirements are and I don't want to be stuck with bills for the consultations, tests, etc. and be denied for surgery. I've called the insurance company, and I can't ever seem to reach anyone who can "spell out" for me what I need to do to be approved. They just keep telling me that I need to see a surgeon, etc. Is there someone specific I can ask to speak with who can help me? MY PCP just ordered a "preliminary sleep study" (his terminology)--I had to wear a pulse oximeter overnight at home to keep an eye on my oxygen saturations. He said that it was not indicative of sleep apnea, so there was no need for a full blown sleep study. This was for overall health, not specifically for WLS qualifying. Will that hold up with the Ins. company or will I still need the sleep study?? Thanks for all your help! This board is fantastic!! Chris    — Chris B. (posted on September 9, 2003)

September 9, 2003
it's hard to get an straight answer from the insurance company just by calling them. the best thing to do is ask them to send you their insurance handbook. this spells out in black and white everything you need. depending on what insurance company you have, some of them have their handbooks online to look at. always know what you are dealing with BEFORE you start this process. if you have tests done now and you are able to have the surgery, most likely you will be having all the test done over. each wls doctor has different test they want you to do and some of them have a certian time frame they must be done in.
   — franbvan

September 9, 2003
When I first became interested in having the surgery, I talked with someone who had it done. I went to a support group meeting that the hospital holds and got information from them (it was free). In order to qualify health-wise for bariatric surgery, you had to be 100 pounds overweight, have a BMI of 45 or more, or have several medical problems such as sleep apnea, reflux disease, or family history. Only your doctor can tell you what their specific qualifications are. I contacted my insurance company and they told me I had to see my surgeon and I was required to have a referral from my primary care physician. When I went to the surgeon the first time, I was so scared because I really thought I would not be able to be approved because I didn't have "that much" wrong with me or I wasn't old enough or hadn't suffered with these problems long enough. Turns out, I am the perfect age because I have such a strong family history of EVERYTHING. I already have high cholesterol, hypothyroid, and acid reflux. I am just well on my way with the predisposition of having diabetes, high blood pressure, and heart disease, so you see that it is best for me to have this surgery now to try to ward off these diseases. I guess in short, my answer is, go to a local support group that your hospital offers and you will have to talk with a surgeon who does this kind of surgery. Not what you want to hear when cost is a factor, but that is what has to happen.
   — Tracey

September 9, 2003
Your surgeon would know. The best thing to do is pick your surgeon and let them handle it.
   — Delores S.

September 10, 2003
Chris, your profile says you have Aetna. Here is a link to Aetna's coverage policy bulletin. http://www.aetna.com/cpb/data/CPBA0157.html
   — Tom Barton

September 10, 2003
I recommend you find out exactly what your insurance's criteria are before too much longer - you could be taking care of important steps already. You need to call member services (customer service) and ask "What exactly are the criteria for gastric bypass surgery to be paid under my policy." Then call the precertification (authorization) department and ask the exact same thing. If you get two identical answers, it is probably good info. If you get different answers, call back a few days later and ask again. If you can't get a straight answer, put your request for info in writing and ask for their fax number. Always get the name of the person you are talking with and their extension. I did this and got nearly-identical answers the three different times, but when it was time for my surgery to be authorized they had a slightly-different list of criteria, but luckily it was easy to document the rest of it. I disagree with letting your surgeon handle it. Your surgeon's office has hundreds of patients to deal with, and you are important, but it will be money out of your pocket, and/or time out of your life, if something doesn't go right paperwork-wise. You are the one getting the care, it is your responsibility to get this info yourself. The people who issue the authorizations are the best people to advise you of the required documentation - so the precert department is the most-reliable source. If you still don't get anywhere, get your personnel department at your job (or hubby's job if it is his policy) involved.
   — bethybb

September 10, 2003
Go to Aetna's website - Aetna.com - and get on the navigator and look up alphabeticaly under obesity surgery or somethng along with that title. Print out the requirements, and then you'll know exactly what you need to have done and to qualify to get approved. It's not that hard. Also, I hope you get back on to check on this before this goes off of the msg board. Look up the question below "how much do I provide insurance on the 1st try". There is helpful info on that question also. One more thing, look up in the Library under Aetna, and there are tons of questions in there that might be helpful.
   — bufordslipstick