Advice about Coverage!

So I been posting about my insurance, so now I have my new insurance. I know I could just call and get the information from the insurance provider, but kind of nervous. I didn't want to get my hopes up, so I decided to ask my OH family their input. So my insurance states:

They have a list of excluded services... OKAY that was good..

Then they have a list of covered services. It says BARIATRIC SURGERY but here is the part I don't understand.. In parentheses it states (Only Morbid Obesity in Limited Cir****tances). I don't understand what that means. If someone had this in their insurance book or coverage, please help me understand. Any information is greatly appreciated as always. Thanks guys! xoxo

Mimi J

If I were you, I would call them and find out what they mean by it, in writing if possible. Having a copy of your medical policy is always good, you never know when you will need it. It could mean a 40+ BMI with co-morbidities but which co-morbidies and other things it could be you would just be guessing at. It is better to know all of the facts.

I say this because I had to appeal several times and I needed things in writing. You never know when you are going to get thrown a curve ball so good to be prepared :)

Also, write down the name of who you talked to and the date if you decide to call them.

Good morning, Mimi - so, okay, I work in health insurance - so here's the scoop.

" Only Morbid Obesity in Limited Cir****tances" = a pretty tight rein on who does or does not qualify.  That being said - there are always exceptions!  If you find out the requirement is a BMI of 40 with at least two co-morbids and you have a BMI of 39 and two or three co-morbids, don't automatically assume you won't qualify!

Other things are taken into consideration such as "quality of life".  How does your weight affect your quality of life? 

Find out the requirements.  Determine if you are in the "ballpark".  Make sure the documentation that your WLS submits to the insurance company is comprehensive and includes everything you want the insurance company to know about your situation.  Doing it right the first time lessens the chances that you'd have to file an appeal.

Sandie

Don't be nervous. Given your BMI is 62, they really don't have any reason to deny you. Morbid Obesity is defined as having a BMI greater than 40. At 62, you're considered super-super-morbidly obese, so you shouldn't even need any co-morbs to qualify.

I strongly urge you to research a form of WLS called the Duodenal Switch, DS for short. The DS has the very best long-term, maintained weight-loss stats for patients of any size, but this is especially true for those of us with a BMI greater than 50.  It's also the very best at resolving or preventing co-morbs like diabetes and high cholesterol.