Question:
I'm still confused! Is it the surgeon or the insurance company?
Who decides what procedures are required before approval for surgery? I've read so many messages about psych exams, upper gi series, pre-op diets etc. etc. When I spoke to my insur. carrier I was told that my policy allowed for bariatric surgery when deemed medically necessary, including the lap band. However,it seems like there must be more to it than just getting my PCP or Surgeon to say that I need it. My BMI is 37 and my only co-mordid conditions are, degenerative disc, depression, heavy/irregular mentrual bleeding and general joint aches and pains that come with carrying around extra weight. Anyone have any insight? Thanks! — [Deactivated Member] (posted on September 15, 2005)
September 15, 2005
Hi. Let me try to answer your question by telling you what happened with
me:
My insurance needed a few things, like my weight history, a letter from my
PCP saying that I need WLS, a diet attempts history, and a psych eval. Did
all that, and after a about 1.5 years, I got approval. (That was paritally
my fault... I didn't stay 'on it' with the calling and everything)
Okay, so got my approval.
Now that I have that, my surgeon requires very extensive pre-op tests. I
did that last week. Those are paid for by my insurance, because I was
approved for the WLS, and also for any treatments related to it that my
surgeon would require.
So, your surgeon may want a whole bunch of testing done, or he may not need
many tests at all.
Right now, your main goal is to find a surgeon, and get insurance approval.
Usually their office can help you with that.
Also, if you have ever went to your PCP about any of your comorbs, have
him/her write a letter about your problems, and how WLS would help those.
Any questions feel free to drop me a line through my profile!
Amanda
PS) Sorry for any spelling errors... I'm just going to send this without
spellchecking... I'm tired! =)
— AmandaLeigh =)
September 15, 2005
Howdy, This is how it worked with me.My family dr. had to give me a
referral to a weight loss surgeon. After my consulation he gave me a list
of things I needed to get done for him and for the insurance company.The
Insurance company wanted a letter from my dr. and my surgeon saying that
weight loss surgery was medically necesary, six months diest documentation,
phyc eval. and any comorbs I had due to my weight from my Family physician.
My surgeon wanted test done on my heart, lungs, sleap apnea things like
that to make sure I was fit for surgery. So to answer your questiong Both
the insurance and your surgeion will ask for tests.
Your WLS Sister
Conijo Michalko
375/160/140
— Jo_Michalko
September 15, 2005
I called my insurance co. first to see if the surgery was covered and then
they said I needed a letter from my PCP , a psych evaluation and a diet
history after that the surgeons office took care of everything, all the
other tests sleep apnea, gallbladder ultrasound, venus doppler (leg vein
check) were all ordered by surgeon. Good Luck I started my journey in May
and finally have a date Sept.29th it's a long process but well worth it
Take Care Pamela Tweedie
— sunnie
September 15, 2005
Hi! My BMI is 39 and I have a family history of heart attack, stroke and
cancer. My co-morbids are reflux, asthma, joint pain, feet problems and
depression. I started my journey in May 2005 and my surgery is scheduled
for October 5. The only thing I was required to do was meet with my family
physician to get approval, then meet with the WLS. After I received
approval and a date I had to schedule to meet with the anesthesiologist and
the nutritionist and have a physical from my family doctor within 7 days of
my surgery. That's it--no sleep apnea and all the other testing people
talk about. Best wishes to you! I'm counting down the days to a healthier
me!!! I wish the same for you!!!!
Lezlie :)
— Lezlie
September 15, 2005
Hi,
First offs high enough to warrant this surgery without any
other problems. Second, it is pretty much up to the Insurance what type of
surgery you have. Some don't cover
the band, so that leaves only the RNY. Everyone has to do
certain testings prior to having surgery (that is for your own good) and if
you don't have any done I would change Dr.
right away. The phych eval is important to find out if you
are able to handle this procedure as it is life treatning to have &
also changes your life drastically. It is not a cure & you have to
work at getting & keeping the weight off
just like before. This is not an easy way out for being fat, it is darn
hard work. So with that, if you still decide
to go with this surgery. I don't think you will ever regret it & you
will be on the road to a healthier you than you have ever had in your
lifetime. Good luck & hope you get what you set out for. Hope this
helps a little. by the way
where do you live? & who will your Dr. be?
Marilyn, the Bearlady
— Marilyn C.
September 16, 2005
Your insurance company usually has some things you need to do to prove that
the procedure is medically necessary. I had to have it documented that I
tried to lose the weight by dieting (more!) for an additional six months.
I also had to have a psychiatrist, exercise physiologist, and dietician
sign off on it. I had to have my comorbidities validated by going to a
cardiologist for my high blood pressure, a pulmonary specialist for my
sleep apnea, and get an endoscopy and a colonoscopy. I also had to have my
PCP send a letter to the insurance company.
some insurance companies do not require you to jump through aas many hoops,
I hear.
Your best bet is to call or visit your insurance company online to get an
exact idea of what to do. Your surgeon's office may also have some
information.
— Novashannon
September 16, 2005
Hi. I noticed you have a PPO which means that you won't need a referral
from your PCP. All you really need to do is find a surgeon, one that is
in-network, and then make an appointment. The surgeons office will usually
take over after that but it's mainly the surgeon's office that will set you
up with all the tests, exams and consulations with the nutrionist etc.
Please please verify that these people are all in-network because you don't
want to be caught off guard. Oh, also make sure you ask your surgeons
office if they're are any additional fees that are not covered by
insurance. I'm sure they will have some. Good luck to you!
— J. Bee
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