Priority Health HMO and Lightweights

Hi!  Anyone outhere with PH who is a lightweight with secondary co morbs only?

My BMI is 40.5,  I have been in MMPC's medical weight loss program for 3 years.  I have done the fast twice and been Very successful SHORT TERM!  I have regained it all both times.  I faithfully go to behavior meetings.  I have secondary co morbs like high cholesterol when I'm overweight.  It goes down to normal when I lose.  Urinary stress..., previous gallstones, joint pain, wacky periods, I am going for a sleep study soon because I have some symptoms of apnea.  What if I don't have it? I need help to find some loop hole.  My PCP says that if I don't meet the requirements on the list they won't cover it period!!  Is this true?  Is there any way I can convince them that I need this surgery?  How about the fact that the heavier one becomes the higher surgical risk they are? How about wanting to fix this now before I get to the point where I have "Life Threatening" issues?

HELP ME PLEASE...Laura

Have they tried to get the surgery pre-authorized from Priority Health.  It seems to me that you do meet the medical critera.  That is where I would start.  Have MMPC send to Priority Health to see if they can get it autorized.  It sounds to me like you are a good candidate

I am in the process of getting the paper referral from my PCP.  I have to have the sleep consult before he will do that. Which criteria?  I can't figure out where I fit in.  They (PH) want you to have the MAJOR co morbs!

Well, my BMI is over 40 so I only need to have 1.  Technically, I have NO MAJOR co morbs.  I have plenty of minor, secondary ones. Tell me what you're looking at specifically.  Maybe you are my missing link. LOL  Thanks, Laura

Laura, You remind me so much of what I went through. I also have Priority Health. I have (had) a BMI of 40.5 and secondary co-morbs as well (high cholesterol, bursitis). I had to be submitted, twice, because the first time I always thought I was 5"6" and when Dr. V's office remeasured me, I was 5' 5 1/2. That made me go over the BMI.  Dr. V's  assistant said a lot of time with PH, it depends on *****views your chart. After she resubmitted, I got approved... I just re-read my first reject letter and it sounds like they'd rather have you really sick when you have the surgery than doing something preventative to not get you to that point. I agree with you whole-heartedly.  Have you seen a bariatric surgeon yet? I really understand what you are going through..... deb

Each insurance company has their own medical critera you need to meet in order to be eligible for gastric bypass surgery,  Unfortunatly I do not know what Priority Health's is.  I would suggest calling them to see what it is.   The majority of them is a bmi of greater than 40.  The co-morbid conditions depend on your bmi.  MMPC is really good at letting you know if you meet the critera.  I don't know if this is an option for you or not, but do you have the option of changing carriers at the first of the year.  I know you would probably meet the medical criterea for Blue Cross (you do have 12 consecutive months of documented weight loss attempts correct?).   You may want to check that option.

Hi Laura, Hopefully I can be of some help. I also have PH. First thing I did was go to Dr. Glucks (bariatic surgeon) seminar. I then had my PCP right a letter requesting that I have wls. My BMI was also low...41. I did have high cholesterol, urinary stress, high tryglycerides (goes with high cholesterol a lot) and I complained of mild depresstion and relfux. I went on a prescription for everything to show that I needed this surgery. I was denied first time and was told to go through the Medical Weight Loss program at Mercy for six months. I did that. Then the weight loss program sends that info. to my ins. co. to get an approval to go see Dr. Gluck for an evaluation. He then ordered medical tests. I did that. Another letter from my PCP had to go to the Ins. Co. It needs to be a really strong letter to get the point across that you need this surgery for your health. By this time I was having a problem with blood sugar. I did not need any meds. for it , but it was elevated some. So my PCP added this also. After all the tests from your surgeon is completed, YOUR letter about why you need this, and a letter from your PCP again, the surgeons office sends it all back in again. We have done this and I am now waiting for the stamp of approved. Dr. Glucks staff has said they have never seen it  not approved after they have approved you for all the testing and a consult with your surgeon. I was told that should be in next week.  Then I can get a surgery date....it will have been a long time coming, but it will be well worth the wait. It sounds like you have everything you need. It helps a lot to have your surgeons office helping with all this. They know all that needs to be done and when. Hope this can help. colleen

Oh my goodness!!!  Thank you all so much!! Yes, I will be going with MMPC, probably Dr. Kemmeter.  I have been going to his office for 3 years, but in the medical program. I was told after I attended their orientation that I neede a referral from my PCP.  They (MMPC) had put this form to be filled out in my orientation folder.

I took the form to my PCP and he seemed less than enthuised...but he went over a few things and did say that I have several symptoms of sleep apnea, so I am now scheduled for a consult.

I could use any help and advice you have.  I would like to only have to submit once.  I will start making a list of everything I need. It sounds like I NEED a PCP who is thrilled and excited.  I will see where the sleep consult leads and work on that then....

Laura

Laura, It does help a lot if your PCP is in favor of this surgery. It is his letter that will count if your approved or not.  My sister changed her PCP' for that reason. I did have a sleep apnea consult but seen my surgeon for a consult before the sleep study. Dr. Gluck said I did not need it as I was already approved for his evaluation. I did not feel like I needed it anyway, I was just doing it just in case I needed something else wrong with me...wow, I wanted something else wrong with me...hard to imagine. You shouldn't have a problem getting approved, especially since you have already went through the weight loss program. Good Luck, colleen

Laura, I think you need to talk to the folks at MMPC to help you with the steps to get approved. If your PCP isn't really enthusiastic about it, then go to the people who are.  As I mentioned earlier, my bariatric surgeon's office knew who to contact at PH to get an easier approval. Insurance companies can be a pain.  I use to work in Labor and Delivery and we used t say that insurance companies would rather pay for pregnancies than birth control! PS-I'm honored that you asked to be on my friend's list..... Deb

Thanks Colleen! Thanks Deb!  I think I will try to give them a call on Monday.  Maybe I can get more answers directly from  the surgeon's office. I really don't want to go to a consult that I don't need. Laura