No Approval Necessary? Carefirst PPO

On Monday, January 8th I had my first appointment with the surgeon's office to start the LapBand process. On Thursday, January 11th I received a call from his office saying my insurance had approved the procedure without them having to provide any documentation. This REALLY concerns me as I've never heard of anyone being approved without having to do something (diet, psychologist, nutritionist, etc).  I called CareFirst Member Services, the PreCertification department, and the Utilization Management department to be sure and they all agreed that precertification/authorization is not required. They documented everything in my file incase it comes up in the future, but I'm still REALLY doubtful. They also won't issue a letter of approval since technically they haven't approved it.   Has anyone ever heard of this or have any experience that can help me?  On a happy note, if it's true my surgery date is February 2nd. :) Thanks!

Yes, actually there is a poster named Nursemary.  She didnt have to do the pre-diet, or much else either.  Three weeks after she went to the doctor, she had her surgery scheduled.  Maybe you can look her up on OH.    She had the vertical sleeve procedure, but it is still WLS.... and doing very well I might add.   I admit to a tad bit of envy because I would go tonite for surger if my insurance would let me, but I am just starting my 6month dr. diet. I am happy for you too!! But because it is happening so fast,  do a lot of research okay?

Thanks for your response!  I tracked down nursemary and read her story.  I'm still not feeling too comfortable, but I sent an email to my Member Services again so hopefully this time I can get something in writing.  They're going to hate me. :) 

Hi. I would definitely clarify all of that with your surgeon's office. I know that my surgeon's office called the other day to let me know that the surgery would be covered, but it was just a verification that coverage is provided for the surgery, not an actual approval. I would be hesitant to believe it until I have an approval letter in hand. Of course I learned the other day that even the approval letter isn't a guarantee of payment. Everything is reviewed again after the surgery is performed and then either approved or denied. Apparently it isn't common that they won't pay after the initial letter, but it can happen. Either way, they can't go back in and undo the surgery once it is done so in my eyes, if that should happen and you make an effort to pay what you can on a regular basis the surgery/ outcome is worth it with or without insurance paying for it. (make sense? sounds like rambling to me, oh well) Jenifer

Thanks for your response! :) I talked to the nurse and got some clarification today when I was in the office doing my visit to the nutritionist.  Apparently my insurance doesn't do the preapproval - they do postapproval.  As long as I have documentation of everything they require, I should be fine.  It's the 'should be' that kills me.  I once again contacted member services this time in writing asking for the information again.  They're going to hate me soon. :) 

Jess, I was in a similar situation-when we initially contacted the insurance administrators (company is self insured) I was told the  company did not do pre approval and I really did not need one.  My surgeons office was not satisfied and faxed over all the documents and asked for an approval in writting.  A few days later I received a copy of a denial letter (original sent to surgeon) stating that I was denied because I did not do a three month supervised diet. I am now doing the three month diet and am really glad I found this out before I had the surgery and would have been denied.  I am sure all companied are different.  The inportant thing is to keep detailed records of who you speak to , what they saw, and if at all possible, get something in writing-even if it is just an email. Best of luck, Lisa R

Just as a follow up, everything worked out fine.  I had lapband surgery on 2/2/07.  CareFirst covered everything but 20% of my surgeon since he was out of network.  I did not have to submit any sort of medical documentation, proof of diet, etc.    Thanks for all of the help!

Jess, Hey there. I was wandering through these posts and I found yours. I also have Care First PPO. And you may have just shined a ray of hope on me. I have the 40 BMI and all that but was worried about them needing 6 mos supervised diets and all that stuff. I have my consult in Thursday so we will see how things go. WOW. laura