healthnet doesnt cover the sleeve ??
The sleeve is covered by Health Net. Look up their most recent medical policy.
HOWEVER....they are ******** about actually approving it. I was denied twice.....at the initial application and on appeal. This is even after a rep told me that I was likely approved. My doctor office told me that they called Health Net....Health Not...because they are really bad about approvals and always give people **** That being said I know of several people on here that had Health Net and were approved quick with no problems.
Their issue is that they don't consider the sleeve "mainstream" and make you PROVE that you require a sleeve vs RNY or Band.
The "proof" they require is in the form of documented stomach issues (IBS, Chron's, previous abdominal surgery, etc.). They claim that anti inflammatory medication use is also an approved reason but they denied me. I may have won eventually after an appeal to the CA dept of managed care....but it never got that far.
My insurance changes Sept 1st and I am not only getting better insurance coverage but I am now able to access a better surgeon so things worked out for me.
I wish you the best of luck......make sure you document any of those above issues and go check out their medical policy and it will spell out exactly what you need to do.
I think you also need a 40+ BMI, or 35-40 with comorbidities. They also required a psych exam and dietary consult....but no supervised diet.
HOWEVER....they are ******** about actually approving it. I was denied twice.....at the initial application and on appeal. This is even after a rep told me that I was likely approved. My doctor office told me that they called Health Net....Health Not...because they are really bad about approvals and always give people **** That being said I know of several people on here that had Health Net and were approved quick with no problems.
Their issue is that they don't consider the sleeve "mainstream" and make you PROVE that you require a sleeve vs RNY or Band.
The "proof" they require is in the form of documented stomach issues (IBS, Chron's, previous abdominal surgery, etc.). They claim that anti inflammatory medication use is also an approved reason but they denied me. I may have won eventually after an appeal to the CA dept of managed care....but it never got that far.
My insurance changes Sept 1st and I am not only getting better insurance coverage but I am now able to access a better surgeon so things worked out for me.
I wish you the best of luck......make sure you document any of those above issues and go check out their medical policy and it will spell out exactly what you need to do.
I think you also need a 40+ BMI, or 35-40 with comorbidities. They also required a psych exam and dietary consult....but no supervised diet.
SW 229 
CW 136 
As a case manager, I learned a bit about navigating the health insurance companies. First do you have any complex health conditions or diagnosis? If so, contact your health insurance and request a case manager. This person is going to be your advocate. Once you have a case manager you are going to plead your case with them so they can take it up with the special board. This is the "back door" of the approval process. Make sure to let the case manager now how the sleeve is going to improve your health condition, save the insurance company money (huge benefit), improve your quality of life, manage your health and not be dependent on any medications. They want to see measurable outcomes. Then explain why you do not feel the bypass is right for you (risk of malnutrition, history of lack of med compliance, whatever). Then, when/if they deny it, appeal, appeal, APPEAL! Ask for your teams help such as your primary care physician, your family, your psychologist, psychiatrist, nutritionist, surgeon, any one who can write a letter to the insurance company stating that they can attest that this procedure will be of great health benefit to you and improve your existing medical condition.
As a last resort, contact the legal rights society in your state/area. They may take your case.
Hope this helps!
As a last resort, contact the legal rights society in your state/area. They may take your case.
Hope this helps!
"The grass is not greener on the other side, it's greener where you water it. " HW: 258 CW: 222 
You also have to remember health insurance is not the same accross the board. Just because we both may have Health Net- our specifics under the plan are different. If you get your insuance through ya job- it's going to depend on what they negotiated with the company and what plan they picked. SO yeah- one person has it covered 100%- another get's approval- another denied. All depends on your specific plan. The people at the Dr.s office know general information about your health insurance but not specifics- so you should always call and check yourself. Especially call and check on your surgery- make sure their hospital is covered- sometimes they cover teh Dr and surgeon but not the hospital they perform it at. It's crazy big biz bull****!
It's actually in HealthNet's national medical policy, which doesn't discriminate based on what particular plan you have. If your plan covers WLS, it covers the sleeve but you have to prove you're not eligible for RNY or DS.
www.healthnet.com/static/general/unprotected/pdfs/national/policies/Bariatric_Surgery_Jan_11.pdf
"*Note - Medical necessity for laparoscopic sleeve gastrectomy (LSG) as a standalone procedure may be considered when there is a clinical cir****tance for which Roux-en-Y gastric bypass (RYGB) or duodenal switch (DS) is contraindicated. Such may include those patients with existing anemia, inflammatory bowel disease, ulcerative colitis, Crohn's disease, extensive prior surgery (especially with large incarcerated hernias of the lower midline), celiac disease, a previous methicillinresistant Staphylo****us infection and/or other complex medical conditions that would place them at high risk for surgery. Individuals who need to take antiinflammatory medications may also fit into this category because these medications need to be avoided after a RYGB because the risk of ulcer is higher"
But if you have an HMO, they will give you the run-around more than if you're PPO. Jenn got crazy lucky with her medical group that seems to have a good relationship with HealthNet. It may be worth it to temporarily swap medical groups if you are HMO, just to try to submit with them in your appeal. I am fighting the same battle here - I haven't submitted to insurance yet because I want to get EVERYTHING I possibly can so they can't say no. I am hoping that because there are several diseases rampant throughout my family that require steroid and NSAID use that they will not try to mess with me.
Good luck. Try calling healthnet and asking them exactly what they want. That may help.
www.healthnet.com/static/general/unprotected/pdfs/national/policies/Bariatric_Surgery_Jan_11.pdf
"*Note - Medical necessity for laparoscopic sleeve gastrectomy (LSG) as a standalone procedure may be considered when there is a clinical cir****tance for which Roux-en-Y gastric bypass (RYGB) or duodenal switch (DS) is contraindicated. Such may include those patients with existing anemia, inflammatory bowel disease, ulcerative colitis, Crohn's disease, extensive prior surgery (especially with large incarcerated hernias of the lower midline), celiac disease, a previous methicillinresistant Staphylo****us infection and/or other complex medical conditions that would place them at high risk for surgery. Individuals who need to take antiinflammatory medications may also fit into this category because these medications need to be avoided after a RYGB because the risk of ulcer is higher"
But if you have an HMO, they will give you the run-around more than if you're PPO. Jenn got crazy lucky with her medical group that seems to have a good relationship with HealthNet. It may be worth it to temporarily swap medical groups if you are HMO, just to try to submit with them in your appeal. I am fighting the same battle here - I haven't submitted to insurance yet because I want to get EVERYTHING I possibly can so they can't say no. I am hoping that because there are several diseases rampant throughout my family that require steroid and NSAID use that they will not try to mess with me.
Good luck. Try calling healthnet and asking them exactly what they want. That may help.
~Marisa~
Most Active
Recent Topics
