Question:
Can someone tell me what they think about this email I got from ins?

Hi I sent an email to my ins company and this is what I said and they responded. What do you think? I am inquiring about my policy benefits for surgical treatment for morbid obesity. Is Surgery for obesity a covered benefit? Do you cover the cpt code for gastric bypass 43846 and ICD-9 code 278.01? Do you have a policy on surgery for morbid obesity I can obtain? What information do you require to authorize surgery? Where can my PCP/Surgeon Fax authorization request and to who's attention should the fax be directed to? What records does my PCP need to fax to you to obtain authorization to see the surgeon? Who should request the surgerical procedure? Please email me the answers to my question ASAP. Thank you my wls progess member # Dear Ms. : We are in receipt of your recent e-mail requesting benefit information. Coverage for Gastric Bypass Surgery is available in accordance to the Maryland Mandate Legislation Laws established in October 2001. However, services leading up to the surgery (services with a diagnosis of morbid obesity) are not covered by the Health Plan. All requests for Gastric Bypass surgery are reviewed by our Clinical Care Coordination Department (CCCD) for possible authorization approval. Your referring physician is required to submit a Gastric Bypass Request Form (to include supporting medical documentation) to our CCCD. The referring physician may obtain the form from our Professional Services Department by contacting their line directly at XXX XXXX The referring physician may fax the request and information to XXX XXXX Once the form is received by the Health Plan, prior authorization must be established before the surgery would be considered for approval. Any services related to morbid obesity (except services approved by CCCD) are not covered by the Health Plan. Please refer to your Evidence of Coverage (EOC) booklet for the guidelines/exclusions related to treatment of morbid obesity. As a reference, coverage for specific Current Procedural Terminology (CPT) codes related to Gastric Bypass Surgery will be determined within the authorization established by CCCD if approved by the Health Plan. The Health Plan follows the guidelines and regulations established by the National Institute of Health (NIH) for obesity treatment.If you have any additional questions and/or concerns, please feel free to email me directly at XXXXX or contact me at XXX XXXX at extension . sincerely, JG Senior Representative, Customer Support "Exceptional Care From The Heart" AMOS MOD NOTE: We removed the phone numbers from this post    — MyWlsProgress (posted on August 8, 2003)

August 8, 2003
it sounds like WLS is probably covered if you meet criteria. Like they said, read your insurance information. I'm betting a lot of your questions can be answered by doing that.
   — koogy

August 8, 2003
Sounds like how my health insurance works. My PCP must submit the referral information to my insurance company all at once...so that means he must also do all my referral to the Psychologist, Sleep clinic to test for Apnea, and any other specialty testing that needs to be done while still meeting all the criteria such as at least 100 lbs overweight, 2 co-morbids, etc. I must jump through all their hoops and then when everything is submitted, they will decide if I am approved and who I can go see as a surgeon. So it does sound possible that WLS can be covered...just may take a while.
   — ImANewDee

August 8, 2003
Your PCP needs to find out if they require a psych eval or sleep study before approval. My guess is they do not. It sounds like your PCP must submit their particular form and provide all of the info requested, which I'm sure includes a letter and office notes etc. Then they will review and approve or deny. At that point you would be able to go to an in-network surgeon knowing you already have approval. <p>At that point if the surgeon requires the psych eval, sleep study etc. most likely it will be covered as a requirement for surgery. If you do these things ahead of time, and the insurance does not require them for approval, then you will most likely end up paying for them and trust me they are very expensive. Sleep study and interpretation along is $2500. If you have symptoms of sleep apnea, then your PCP should already be sending you to a pulmonologist regardless of surgery. Then if you are diagnosed with SA that could be listed by your PCP on the form. <p>The bottom line is that whatever testing your PCP wants to do before submitting for approval must be ordered with a diagnosis code of something other than surgery, obesity, morbid obesity etc. It must be based on symptoms - daytime sleepiness etc. My insurance only required a psych eval and that is all they would have covered if I was denied. So many doctors are running everything before submitting placing the patient in great financial risk. <p>My surgeon required a sleep study before submitting, but since I already have a daytime sleep disorder the study could be ordered with a non-surgical diagnosis. It had been 5 years since I had one so they would never question it. Besides I had different insurance that year too. My insurance did not require my PCP to submit for approval. I actually saw the surgeon and paid him myself because the insurance I had at the time I started the process did not cover WLS and would not have covered a consult with the surgeon, but I did not want to waste over a month until my new insurance kicked in. So I paid $110 to get the process moving. This can work out but your PCP has to understand your policy and the restrictions so things are ordered correctly and you don't end up with lots of bills. Good Luck! Chris D.
   — zoedogcbr

August 8, 2003
I could be wrong, but this is what it sounds like to me. Gastric Bypass IS covered, however any other things such as weight loss medicines, phychological whatever is not BEFORE wls. At least it seems like what it is saying.
   — Danmark

August 9, 2003
Sleep studies are expensive, but might be covered as a diagnosis of sleep apnea rather that submitting as part of the surgery eval. My insurance also covers only rny as a treat ment for morbid obesity and absolutely no other weight loss treatments, no diets, drugs etc. however my husband has sleep apnea and was evaluated with a sleep study for excessive snoring had all covered, because even tho sleep apnea can be caused by obesity the cpap etc was not treating mobesity but sleep apnea. its all weird huh. anyways, all ins companies are different but go for it - best luck to you!
   — **willow**

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