Question:
Who do I talk to in order to find out specific requirements for surgery?
I have seen several posts regarding getting approval during your physician supervised diet. I'm currently on a program with my physician, having monthly appointments and weigh ins. However, I am not pursuing insurance approval, etc. because I have no idea what the requirements are and I don't want to be stuck with bills for the consultations, tests, etc. and be denied for surgery. I've called the insurance company, and I can't ever seem to reach anyone who can "spell out" for me what I need to do to be approved. They just keep telling me that I need to see a surgeon, etc. Is there someone specific I can ask to speak with who can help me? MY PCP just ordered a "preliminary sleep study" (his terminology)--I had to wear a pulse oximeter overnight at home to keep an eye on my oxygen saturations. He said that it was not indicative of sleep apnea, so there was no need for a full blown sleep study. This was for overall health, not specifically for WLS qualifying. Will that hold up with the Ins. company or will I still need the sleep study?? Thanks for all your help! This board is fantastic!! Chris — Chris B. (posted on September 9, 2003)
September 9, 2003
it's hard to get an straight answer from the insurance company just by
calling them. the best thing to do is ask them to send you their insurance
handbook. this spells out in black and white everything you need. depending
on what insurance company you have, some of them have their handbooks
online to look at. always know what you are dealing with BEFORE you start
this process. if you have tests done now and you are able to have the
surgery, most likely you will be having all the test done over. each wls
doctor has different test they want you to do and some of them have a
certian time frame they must be done in.
— franbvan
September 9, 2003
When I first became interested in having the surgery, I talked with someone
who had it done. I went to a support group meeting that the hospital holds
and got information from them (it was free). In order to qualify
health-wise for bariatric surgery, you had to be 100 pounds overweight,
have a BMI of 45 or more, or have several medical problems such as sleep
apnea, reflux disease, or family history. Only your doctor can tell you
what their specific qualifications are. I contacted my insurance company
and they told me I had to see my surgeon and I was required to have a
referral from my primary care physician. When I went to the surgeon the
first time, I was so scared because I really thought I would not be able to
be approved because I didn't have "that much" wrong with me or I
wasn't old enough or hadn't suffered with these problems long enough.
Turns out, I am the perfect age because I have such a strong family history
of EVERYTHING. I already have high cholesterol, hypothyroid, and acid
reflux. I am just well on my way with the predisposition of having
diabetes, high blood pressure, and heart disease, so you see that it is
best for me to have this surgery now to try to ward off these diseases. I
guess in short, my answer is, go to a local support group that your
hospital offers and you will have to talk with a surgeon who does this kind
of surgery. Not what you want to hear when cost is a factor, but that is
what has to happen.
— Tracey
September 9, 2003
Your surgeon would know. The best thing to do is pick your surgeon and let
them handle it.
— Delores S.
September 10, 2003
Chris, your profile says you have Aetna. Here is a link to Aetna's
coverage policy bulletin. http://www.aetna.com/cpb/data/CPBA0157.html
— Tom Barton
September 10, 2003
I recommend you find out exactly what your insurance's criteria are before
too much longer - you could be taking care of important steps already. You
need to call member services (customer service) and ask "What exactly
are the criteria for gastric bypass surgery to be paid under my
policy." Then call the precertification (authorization) department
and ask the exact same thing. If you get two identical answers, it is
probably good info. If you get different answers, call back a few days
later and ask again. If you can't get a straight answer, put your request
for info in writing and ask for their fax number. Always get the name of
the person you are talking with and their extension.
I did this and got nearly-identical answers the three different times, but
when it was time for my surgery to be authorized they had a
slightly-different list of criteria, but luckily it was easy to document
the rest of it.
I disagree with letting your surgeon handle it. Your surgeon's office has
hundreds of patients to deal with, and you are important, but it will be
money out of your pocket, and/or time out of your life, if something
doesn't go right paperwork-wise. You are the one getting the care, it is
your responsibility to get this info yourself.
The people who issue the authorizations are the best people to advise you
of the required documentation - so the precert department is the
most-reliable source. If you still don't get anywhere, get your personnel
department at your job (or hubby's job if it is his policy) involved.
— bethybb
September 10, 2003
Go to Aetna's website - Aetna.com - and get on the navigator and look up
alphabeticaly under obesity surgery or somethng along with that title.
Print out the requirements, and then you'll know exactly what you need to
have done and to qualify to get approved. It's not that hard. Also, I hope
you get back on to check on this before this goes off of the msg board.
Look up the question below "how much do I provide insurance on the 1st
try". There is helpful info on that question also. One more thing,
look up in the Library under Aetna, and there are tons of questions in
there that might be helpful.
— bufordslipstick
Click Here to Return