Question:
Have some questions about how to get approved for surgery

I have Lifeguard POS plan and was wondering how to obtained approval with them? I believe that I qualify for the surgery I have a BMI of 52.5, I was recently diagnosed with diabetes, I have many weight related problems (to many to mention!!!). After getting my PCP approval, she said that she would refer me to the surgeon once Lifeguard had the procedure approved. Right know she is getting my old records throught Kaiser and then she is going to apply for authorization. I believe that there are Dr.'s in Pleasanton that are contracted through Lifeguard, I live in the South Bay. I called Lifeguard today to get their criteria for the surgery and they said that there are exclusions in EVERY policy for WLS...I was flabbergasted because I just talked to them yesterday and they said that it would be approved if it was medically necessary. I just wanted to get some information from someone who got approved with them and see how they work. Any help would be wonderful. Thank you Dusty    — Dusty S. (posted on May 19, 2001)

May 19, 2001
Certainly there are exclusions to every policy but...you seem to well qualify for this surgery. Definately make sure you include proof for any Dr. supervised diets you have tried before, include ALL co-morbids (there are probably many that you don't even know about) and make sure that the Dr. says that this is imperative to say the least for your life. This is NOT cosmetic but I am sure that your doctor knows how to do this. Most likely if you leave it to the doctor he knows how to get around any exclusion especially because you more than qualify. My doctor did a sleep apnea study before asking for approval but I am sure that many don't. Get a copy of the letter for yourself because I am sure that the insurance company, after 2 weeks, will tell you that they never recieved it and you will have to have the doctor fax it to them again and you should do the same so that they have 2 copies to a specific person who cannot then, say that they never recieved it. I faxed mine and then called an hour later to make sure it was recieved. They couldn't deny getting it after that. Good luck to you.
   — Barbara H.