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poet_kelly’s Posts
Post Date 5/20/10 7:40 pm
Topic: RE: just a little bit of help plz..
Individual insurance plans usually do not cover WLS. All major insurance companies cover it, including Blue Cross Blue Shield, Cigna, Aetna, etc. Your best bet to get insurance coverage is to get a job that provides insurance that covers it. However, just because all major insurance companies cover it, doesn't mean all insurance plans cover it. Employers get to decide whether or not to choose an insurance policy that covers WLS. Some opt to exclude it to save money on premiums. So just because you got a job that had Blue Cross, that doesn't mean your plan would cover WLS. You'd need to check the exact policy offered.
Kelly
Topic: RE: just a little bit of help plz..
Individual insurance plans usually do not cover WLS. All major insurance companies cover it, including Blue Cross Blue Shield, Cigna, Aetna, etc. Your best bet to get insurance coverage is to get a job that provides insurance that covers it. However, just because all major insurance companies cover it, doesn't mean all insurance plans cover it. Employers get to decide whether or not to choose an insurance policy that covers WLS. Some opt to exclude it to save money on premiums. So just because you got a job that had Blue Cross, that doesn't mean your plan would cover WLS. You'd need to check the exact policy offered.
Kelly
Post Date 2/24/10 10:01 pm
Topic: RE: Denied for revision to DS
I suggest calling your insurance company and asking what it means. "Non-compliant," in medical terms, generally means a patient didn't do what the doctor told them to do. It would suggest you didn't follow the diet you got from your doctor or dietician or that you didn't keep appointments for fills or something like that. If that is what they are saying, you can appeal that and provide documentation that you did those things. Things like copies of any food logs you kept, records from meetings with your dietician where you discussed your diet, records showing when you got fills, etc.
If they are calling you non-compliant just because you didn't lose weight, well, if you did everything you were supposed to do and still didn't lose weight, that's not your fault. And duh, the fact that you didn't lose weight is why you need the revision. If they are saying the fact that you didn't lose weight means you were non-compliant, I would suggest appealing and providing them with the same documentation mentioned above to show that you were in fact compliant but the band just didn't work for you.
Kelly
Topic: RE: Denied for revision to DS
I suggest calling your insurance company and asking what it means. "Non-compliant," in medical terms, generally means a patient didn't do what the doctor told them to do. It would suggest you didn't follow the diet you got from your doctor or dietician or that you didn't keep appointments for fills or something like that. If that is what they are saying, you can appeal that and provide documentation that you did those things. Things like copies of any food logs you kept, records from meetings with your dietician where you discussed your diet, records showing when you got fills, etc.
If they are calling you non-compliant just because you didn't lose weight, well, if you did everything you were supposed to do and still didn't lose weight, that's not your fault. And duh, the fact that you didn't lose weight is why you need the revision. If they are saying the fact that you didn't lose weight means you were non-compliant, I would suggest appealing and providing them with the same documentation mentioned above to show that you were in fact compliant but the band just didn't work for you.
Kelly
Post Date 1/12/10 9:55 am
Topic: RE: Exclusions
Generally when there is an exclusion, that means your employer opted to exclude WLS in order to save money on insurance premiums. If that's the case, appealing won't do any good. You have not been paying the premiums to cover WLS, so they won't cover it. It's like, some companies offer both medical insurance and dental insurance. If you only pay for the medical insurance and then need a root canal, well, they aren't going to pay for it because you didn't buy the dental insurance. If your employer excluded WLS, that means you haven't been paying for that insurance. So they will not cover under any cir****tances.
Kelly
Topic: RE: Exclusions
Generally when there is an exclusion, that means your employer opted to exclude WLS in order to save money on insurance premiums. If that's the case, appealing won't do any good. You have not been paying the premiums to cover WLS, so they won't cover it. It's like, some companies offer both medical insurance and dental insurance. If you only pay for the medical insurance and then need a root canal, well, they aren't going to pay for it because you didn't buy the dental insurance. If your employer excluded WLS, that means you haven't been paying for that insurance. So they will not cover under any cir****tances.
Kelly
Post Date 11/21/09 7:02 pm
Topic: RE: Wendy Law? BCBS
Couldn't you just call BCBS and ask them?
Kelly
Topic: RE: Wendy Law? BCBS
Couldn't you just call BCBS and ask them?
Kelly
Post Date 11/8/09 8:43 pm
Topic: RE: NEW WITH THIS...UHC
With most insurance companies, if you have a comorbidity like high blood pressure, you only have to have a BMI of 35, not 40. So that help you. Although, if you just started taking the medication for it, I assume that means you haven't had high blood pressure for five years. So it might not help you after all. I would contact UHC and ask.
If you don't have records of a six month diet, I assume that means you have not done a six month diet? There is really no way around that. Having high blood pressure will not get you out of the six month diet. Start the diet as soon as you can.
Whether you have to pay the portion that you owe all at once is up to your surgeon and the hospital where you have surgery. Some will take payments, but some want paid before you have your surgery.
Kelly
Topic: RE: NEW WITH THIS...UHC
With most insurance companies, if you have a comorbidity like high blood pressure, you only have to have a BMI of 35, not 40. So that help you. Although, if you just started taking the medication for it, I assume that means you haven't had high blood pressure for five years. So it might not help you after all. I would contact UHC and ask.
If you don't have records of a six month diet, I assume that means you have not done a six month diet? There is really no way around that. Having high blood pressure will not get you out of the six month diet. Start the diet as soon as you can.
Whether you have to pay the portion that you owe all at once is up to your surgeon and the hospital where you have surgery. Some will take payments, but some want paid before you have your surgery.
Kelly
Post Date 11/7/09 7:12 pm
Topic: RE: Deductable problem
I would start by asking the surgeon's office if they will take payments. If not, you might look into one of those medical credit cards like Care Credit.
Kelly
Topic: RE: Deductable problem
I would start by asking the surgeon's office if they will take payments. If not, you might look into one of those medical credit cards like Care Credit.
Kelly
Post Date 11/3/09 7:00 pm
Topic: RE: maineCare (its like medicaid)
I have Medicare and Medicaid in Ohio. Medicare was my primary, and Medicaid paid the portion that they did not pay. I did not have to do any pre-requirements like a six month supervised diet. I just had to have a BMI of 40 or above. Each state may have different rules for their Medicaid program, though. And my experience may have been different since Medicaid was my secondary insurance, I'm not sure about that.
Kelly
Topic: RE: maineCare (its like medicaid)
I have Medicare and Medicaid in Ohio. Medicare was my primary, and Medicaid paid the portion that they did not pay. I did not have to do any pre-requirements like a six month supervised diet. I just had to have a BMI of 40 or above. Each state may have different rules for their Medicaid program, though. And my experience may have been different since Medicaid was my secondary insurance, I'm not sure about that.
Kelly
Post Date 11/1/09 8:34 pm
Topic: RE: Aetna - BMI requirement - no proof
Why don't you try calling them and explaining the situation and ask if there is anything you can do? You might want to ask to speak to a supervisor. The person who answers the phone may not know how to help, but a supervisor might.
Kelly
Topic: RE: Aetna - BMI requirement - no proof
Why don't you try calling them and explaining the situation and ask if there is anything you can do? You might want to ask to speak to a supervisor. The person who answers the phone may not know how to help, but a supervisor might.
Kelly
Post Date 11/1/09 12:12 pm
Topic: RE: Aetna - BMI requirement - no proof
They probably will require written proof from a doctor, yes. One thing you could try is sending pictures of yourself over the past two years, if they have the date stamped on them and if it is obvious in the pictures that you are overweight. I have heard that some people have been able to use that to prove a history of being overweight. But I'd say it's a long shot.
Kelly
Topic: RE: Aetna - BMI requirement - no proof
They probably will require written proof from a doctor, yes. One thing you could try is sending pictures of yourself over the past two years, if they have the date stamped on them and if it is obvious in the pictures that you are overweight. I have heard that some people have been able to use that to prove a history of being overweight. But I'd say it's a long shot.
Kelly
Post Date 10/30/09 9:50 am
Topic: RE: United Health Care Choice Plus
You need to call UHC and ask. Even if someone else here has UHC, their plan might be different than yours.
Kelly
Topic: RE: United Health Care Choice Plus
You need to call UHC and ask. Even if someone else here has UHC, their plan might be different than yours.
Kelly
Post Date 10/30/09 9:48 am
Topic: RE: New to this forum and looking for guidance. same post as in the ct board.
If you have an exclusion, what that usually means is that your employer opted to exclude WLS from your insurance coverage. They do this so premiums will be cheaper. The only thing you can do is ask your employer to offer an insurance plan that does cover WLS. Appealing won't help, because you've purchased an insurance plan that does not include WLS. You aren't paying the premiums that cover WLS, so they aren't going to cover it.
Kelly
Topic: RE: New to this forum and looking for guidance. same post as in the ct board.
If you have an exclusion, what that usually means is that your employer opted to exclude WLS from your insurance coverage. They do this so premiums will be cheaper. The only thing you can do is ask your employer to offer an insurance plan that does cover WLS. Appealing won't help, because you've purchased an insurance plan that does not include WLS. You aren't paying the premiums that cover WLS, so they aren't going to cover it.
Kelly
Post Date 10/28/09 7:48 pm
Topic: RE: Anyone know the Diagnosis Code for Psych Eval?
They would probably have to bill it as depression or anxiety or something in order for insurance to pay for it. I don't think there is a diagnostic code for a WLS psych eval.
Kelly
Topic: RE: Anyone know the Diagnosis Code for Psych Eval?
They would probably have to bill it as depression or anxiety or something in order for insurance to pay for it. I don't think there is a diagnostic code for a WLS psych eval.
Kelly
Post Date 10/28/09 4:43 pm
Topic: RE: Appeal Process
Oh. I hate to break it to you, but if your husband's employer has an exclusion to WLS, they aren't going to cover it, no matter what you send them. The thing is, the employer opted to save money by not including WLS in their plan. They have not payed the premiums for WLS. Since you aren't paying for those premiums, they won't cover the surgery.
Kelly
Topic: RE: Appeal Process
Oh. I hate to break it to you, but if your husband's employer has an exclusion to WLS, they aren't going to cover it, no matter what you send them. The thing is, the employer opted to save money by not including WLS in their plan. They have not payed the premiums for WLS. Since you aren't paying for those premiums, they won't cover the surgery.
Kelly
Post Date 10/27/09 1:38 pm
Topic: RE: Appeal Process
Why were you denied? What you need to send them will depend on the reason for the denial.
Kelly
Topic: RE: Appeal Process
Why were you denied? What you need to send them will depend on the reason for the denial.
Kelly
Post Date 10/27/09 1:37 pm
Topic: RE: If they say insurance covers the surgery....
Call a different surgeon. Ask about any program fees. But look at your insurance policy, too. Chances are you will have to pay copays or a percentage of the cost. I mean, it normally costs you something when you go to the doctor, right? Or if you go to the ER, or whatever?
Kelly
Topic: RE: If they say insurance covers the surgery....
Call a different surgeon. Ask about any program fees. But look at your insurance policy, too. Chances are you will have to pay copays or a percentage of the cost. I mean, it normally costs you something when you go to the doctor, right? Or if you go to the ER, or whatever?
Kelly
Post Date 10/26/09 12:13 pm
Topic: RE: If they say insurance covers the surgery....
What is the $5000 for? Even if your insurance covers the surgery, you may have copays, or with some insurance plans they pay 80% and you have to pay 20%. Most insurance companies do not cover everything.
Or is it a program fee? Many surgeons charge a program fee, which covers stuff like the classes you have to go to and the dietician. Insurance usually doesn't cover those things. But $5000 is really high for a program fee. Mine was $150. Then I had to change surgeons because the doc who did my RNY closed his practice. The new surgeon has a $200 program fee. I would not pay a $5000 program fee, if that's what it is. I would find a new surgeon.
Kelly
Topic: RE: If they say insurance covers the surgery....
What is the $5000 for? Even if your insurance covers the surgery, you may have copays, or with some insurance plans they pay 80% and you have to pay 20%. Most insurance companies do not cover everything.
Or is it a program fee? Many surgeons charge a program fee, which covers stuff like the classes you have to go to and the dietician. Insurance usually doesn't cover those things. But $5000 is really high for a program fee. Mine was $150. Then I had to change surgeons because the doc who did my RNY closed his practice. The new surgeon has a $200 program fee. I would not pay a $5000 program fee, if that's what it is. I would find a new surgeon.
Kelly
Post Date 10/23/09 7:22 am
Topic: RE: self pay question
For elective procedures, hospitals often want to be paid up front. After all, if they didn't, many people would simply never pay. Best to check with your hospital and find out what their policy is.
Kelly
Topic: RE: self pay question
For elective procedures, hospitals often want to be paid up front. After all, if they didn't, many people would simply never pay. Best to check with your hospital and find out what their policy is.
Kelly
Post Date 10/22/09 4:06 pm
Topic: RE: BCBS of North Carolina
Different companies require different things. You'd need to get their criteria from them. Get it in writing. Usually they do require more than just a letter from your PCP.
Normally you must have a BMI of 40 or more. 35 or more if you have comorbidities like diabetes or sleep apnea.
You usually have to have a history of obesity. Like, medical records going back for several years showing your BMI has been over 40 for some length of time. With some insurance companies, it's just two years. With many, it's five years.
Often, you must show that you've attempted to lose weight by dieting and it hasn't worked. They may also want you to have tried an exercise program, and maybe prescription diet medications.
Kelly
Topic: RE: BCBS of North Carolina
Different companies require different things. You'd need to get their criteria from them. Get it in writing. Usually they do require more than just a letter from your PCP.
Normally you must have a BMI of 40 or more. 35 or more if you have comorbidities like diabetes or sleep apnea.
You usually have to have a history of obesity. Like, medical records going back for several years showing your BMI has been over 40 for some length of time. With some insurance companies, it's just two years. With many, it's five years.
Often, you must show that you've attempted to lose weight by dieting and it hasn't worked. They may also want you to have tried an exercise program, and maybe prescription diet medications.
Kelly
Post Date 10/21/09 7:08 pm
Topic: RE: Several referrals to this forum!! Crohns and VSG with MEDICA
It is my understanding that sometimes insurance companies that don't normally cover VSG will make an exception if there is some reason RNY will not work for you. Like, I read somewhere about people who have to take NSAIDS regularly getting the sleeve approved, since they could not have RNY due to needing to be able to take NSAIDS. Unfortunately, I can't remember where I read that. But I would try providing your insurance company with documentation of why you can't have RNY since you have Crohns and appealing their decision.
Kelly
Topic: RE: Several referrals to this forum!! Crohns and VSG with MEDICA
It is my understanding that sometimes insurance companies that don't normally cover VSG will make an exception if there is some reason RNY will not work for you. Like, I read somewhere about people who have to take NSAIDS regularly getting the sleeve approved, since they could not have RNY due to needing to be able to take NSAIDS. Unfortunately, I can't remember where I read that. But I would try providing your insurance company with documentation of why you can't have RNY since you have Crohns and appealing their decision.
Kelly
Post Date 10/17/09 11:57 am
Topic: RE: New protocol for submitting to IL Medicaid? Surgery before submitting (Xpost)
This is how Medicare works. They don't pre-approve it. They have a criteria, and if you meet the criteria, the surgeon operates and then submits the bill and they pay it. I had no problem getting mine paid for and I've never heard of anyone having trouble getting it paid for.
Now, that's Medicare, not IL Medicaid. However, if you meet the criteria, I don't see why it should be a problem. And I assume it's not a frequent problem, or the surgeon wouldn't be doing the surgery and then hoping Medicaid would pay him. Because you have to know many people on Medicaid couldn't afford to pay the bill if Medicaid didn't pay it. So the surgeon would end up just not getting paid. My guess is that you don't need to worry about it.
Kelly
Topic: RE: New protocol for submitting to IL Medicaid? Surgery before submitting (Xpost)
This is how Medicare works. They don't pre-approve it. They have a criteria, and if you meet the criteria, the surgeon operates and then submits the bill and they pay it. I had no problem getting mine paid for and I've never heard of anyone having trouble getting it paid for.
Now, that's Medicare, not IL Medicaid. However, if you meet the criteria, I don't see why it should be a problem. And I assume it's not a frequent problem, or the surgeon wouldn't be doing the surgery and then hoping Medicaid would pay him. Because you have to know many people on Medicaid couldn't afford to pay the bill if Medicaid didn't pay it. So the surgeon would end up just not getting paid. My guess is that you don't need to worry about it.
Kelly
Post Date 10/16/09 7:54 am
Topic: RE: united healthcare center of excellence?
If your insurance company requires a Center of Excellence, I don't think there is any way around that. Sorry.
Kelly
Topic: RE: united healthcare center of excellence?
If your insurance company requires a Center of Excellence, I don't think there is any way around that. Sorry.
Kelly
Post Date 10/12/09 4:49 pm
Topic: RE: Horror Stories
I would think all you would need from the insurance company would be written authorization saying they will cover the surgery. Most people get an approval letter. If for some reason they tried to refuse to pay after that, I would think all you would need is the letter in order to take them to court to force them to pay.
Kelly
Topic: RE: Horror Stories
I would think all you would need from the insurance company would be written authorization saying they will cover the surgery. Most people get an approval letter. If for some reason they tried to refuse to pay after that, I would think all you would need is the letter in order to take them to court to force them to pay.
Kelly
Post Date 10/11/09 7:39 am
Topic: RE: Medicare Policy Question...HELP!
If Medicare tells you they will go by your BMI at your consult (which is what I think they will do), I would ask them to fax that to you in writing. Then you'll have it to show your surgeon's office. You don't want to show up for your pre-op appointment and have to argue with them about whether or not your surgery should be cancelled if you lost a couple pounds.
Plus it's just always good to get stuff from insurance companies in writing.
If you need to make sure you don't lose and it's a worry, I recommend adding a protein shake or two to your daily diet. It will give you some calories but little or no fat, plus extra protein that will actually help you heal after the surgery.
Kelly
Topic: RE: Medicare Policy Question...HELP!
If Medicare tells you they will go by your BMI at your consult (which is what I think they will do), I would ask them to fax that to you in writing. Then you'll have it to show your surgeon's office. You don't want to show up for your pre-op appointment and have to argue with them about whether or not your surgery should be cancelled if you lost a couple pounds.
Plus it's just always good to get stuff from insurance companies in writing.
If you need to make sure you don't lose and it's a worry, I recommend adding a protein shake or two to your daily diet. It will give you some calories but little or no fat, plus extra protein that will actually help you heal after the surgery.
Kelly
Post Date 10/10/09 8:26 pm
Topic: RE: Medicare Policy Question...HELP!
I actually have Medicare, but I don't know their particular policy on this. I do know that most insurance companies go with your weight at the consult. Some surgeons actually want you to lose some weight before the surgery, and if your MBI then goes below 40, you usually still qualify for surgery.
Who told you if you drop below 40 you would be cancelled? Medicare or your surgeon's office? You might want to verify that. But if that is the case, then I would just not lose anything. It probably won't be hard to maintain your weight for just a couple weeks, will it?
Kelly
Topic: RE: Medicare Policy Question...HELP!
I actually have Medicare, but I don't know their particular policy on this. I do know that most insurance companies go with your weight at the consult. Some surgeons actually want you to lose some weight before the surgery, and if your MBI then goes below 40, you usually still qualify for surgery.
Who told you if you drop below 40 you would be cancelled? Medicare or your surgeon's office? You might want to verify that. But if that is the case, then I would just not lose anything. It probably won't be hard to maintain your weight for just a couple weeks, will it?
Kelly
Post Date 10/7/09 8:41 pm
Topic: RE: self-pay / reimbursement/ band approval?
I'm guessing that if you self pay, you cannot later fight for reimbursement because your insurance policy probably states clearly in the policy that such surgeries must be approved in advance. I don't know your particular policy, though.
I read an article somewhere about how to get your insurance to pay for the sleeve, and I'm pretty sure they actually suggested just getting approved for any WLS and then asking to switch to the sleeve. I cannot remember where I found the article, though, or I would give you the link. I think your best bet is to talk to the insurance person in your surgeon's office. He or she should probably be able to offer you some good advice. I imagine they frequently deal with companies that don't want to cover the sleeve.
Kelly
Topic: RE: self-pay / reimbursement/ band approval?
I'm guessing that if you self pay, you cannot later fight for reimbursement because your insurance policy probably states clearly in the policy that such surgeries must be approved in advance. I don't know your particular policy, though.
I read an article somewhere about how to get your insurance to pay for the sleeve, and I'm pretty sure they actually suggested just getting approved for any WLS and then asking to switch to the sleeve. I cannot remember where I found the article, though, or I would give you the link. I think your best bet is to talk to the insurance person in your surgeon's office. He or she should probably be able to offer you some good advice. I imagine they frequently deal with companies that don't want to cover the sleeve.
Kelly
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