Question:
After rereading my exclusion policy again and again I think I found something i have
completly overlooked. In the exclusion part of my policy it says "Obesity,services primarily for weight reduction or treatment of obesity. This exclusion will not apply to treatment of morbid obisity as determined by us or your medical group if your medical group authorizes the treatment in advance as medically necessary and appropriate." Does this sound like I can go to a BTC and by pass the PCP letter? I am stessing trying to find a PCP in my medical group who is open to this surgery and not want to write me a letter. I am expecting having a hard time getting past the PCP. Thanks terri — terrie N. (posted on May 31, 2002)
May 31, 2002
If your insurance requires that you have a referral from your PCP for all
specialists then I would assume that you still have to go to them first.
But I am not sure. Good luck.
— Virginia N.
May 31, 2002
I think you will still need a referral from your PCP, but can't say for
sure. If you already have a surgeon in mind, you might call his office
& see if they can give you the names of some PCPs they know are
supportive of the surgery and you can check to see if any of those names
are on your insurance. Good luck.
— Sherry B.
May 31, 2002
terry don't stress first off your condition is consider a disease and not
a condition of just generally being a little over weight. Go to your PCP
give them a big huge packet of all the info you can find on morbid obesity
which is classified as a actuall disease. It even has a code number. also
get together your diet history for the past 5 years and any medcal records
from the past that will help you in your case. Then you need to have your
PCP write a letter of medical necessitty . I would not worry about PCP most
doctors can see after you made a advance effort to put together a packet
for them that you are very educated on the whole procedure and the steps
towards it. they should not say no.
— sheri B.
June 2, 2002
It all depends on your insurance company. I didn't have to have a referral
to a surgeon (I had a PPO) and neither my surgeon nor my insurance company
required a letter from my PCP. My surgeon wrote the letter of medical
necessity even though all my insurance company wanted to prove medical
necessity was my height, weight, blood pressure and bmi.
I would suggest calling your insurance company and asking what their
requirements are. There are so many insurance companies and so many plans
that there is no way any doctor's office can know exactly what your company
wants - you could be wasting valuable time and money getting a lot of stuff
that insn't necessary.
— Patty_Butler
June 2, 2002
When I called my pcp for a refferal letter He refused to write one for me
also,so I just made an appointment to see him and had a long talk with him.
He said that He belived I would have a lot of side affects from the
surgery.I told him I had been researching the surgery and I knew about all
the problems I could have, but that a lot of people get along fine.I told
him that if anyone should know I need to lose weight it was him. He did
write me a very good letter that may get me approved but He still doesn't
want me to have this surgery.
— Elizabeth C.
June 4, 2002
Do you have an HMO or PPO. If HMO, the Dr.'s loose money if they refer you
to surgery. Kind of a reverse incentive to the Dr. If your Dr. is opposed
to WLS, I would be finding a new PCP ASAP.
— Dell H.
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