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Did you set goals for 2013? Would you like to create new goals or continue to work on goals you've already set?
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This can be OUR YEAR for OUR GOALS!!
what kind of questions did the psycologist ask? What did you say to have him approve you?
I was declared depressed in college by an on campus therapist. i told him it was due to how heavy i was. and my rapid gain. i gained 30+ pounds in a little over a year.
I think it is really dependent upon your policy. You can certainly try to get around it by going after a "medical necessity" argument, but they might come out and say that it is excluded, for all reasons. If that is the case, then you are out of luck insurance-wise and will have to pursue a cash-pay basis. You might have less expensive alternatives, however, if you pursue Mexico or other overseas alternates. Of course, you always have the right to consult with an attorney who specializes in health care law from the patient view-point - they might be able to help you with appeals.
I did have my surgery last month - 12/27. I must say, I almost feel like I haven't had it at all - except that I've seen the pictures and I am never hungry. I went back to work after a week and feel great (tired, but great!). I would do it again in a heartbeat, and wish I had done it 9 years ago when I was first looking into it.
Good luck!
HW: 274 | SW: 232 | CW: 137 | Goal: 145 (ticker includes a 42 pound loss pre-op) | Height: 5'4"
M1: -24 (205) | M2: -14 (191) | M3: -11 (180) | M4: -7 (173) | M5: -7 (166) | M6: -8 (158) | M7: -11 (147) | M8: -2 (145) | M9: -3 (142) | M10: -2 (140) | M11: -4 (136) | M12: -2 (134) | M13: -0 (134) | M14: -3 (131) | M15: +4 (135) | M16: +2 (137)
I received a letter in the mail yesterday from BCBSM with the information that was provided to me over the phone earlier this week. I know that many BCBS plans are different, but I thought I'd share what my letter stated as far as coverage is concerned for bariatric surgery.
P.S. - I have Blue Cross Blue Shield of Michigan - Community PPO
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Gastric Bypass / Adjustable Gastric Banding Surgery
Fact Sheet
Approved bariatric surgical procedures, including sleeve gastrectomy, are considered established for the treatment of morbid obesity if all of the following criteria are met:
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The patient has a body mass index greater than 40, or a BMI of greater than 35 with comorbid (accompanying) conditions such as degenerative joint disease, hypertension, hyperlipidemia, coronary artery disease, presence of other atherosclerotic diseases, type 2 diabetes mellitus, sleep apnea or congestive heart failure.
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Risks and benefits of the planned surgery, including those related to the patient's age, should be documented in the clinical record. BCBSM has no age requirements for bariatric surgery for adults.
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The patient must be clinically evaluated by an M.D. or D.O. The physician must document, in the medical record, the failure of non-surgical efforts to lose weight. The document must include that the patient participated in a structured, professionally supervised (physician or non-physician) weight-loss program for a minimum of six consecutive months within the last four years prior to the recommendation for bariatric surgery. (The requirement to participate in a weight-loss program is waived for super morbidly obese individuals who have a BMI greater than 50.) Documentation also should include periodic weight, dietary therapy and physical exercise, as well as behavioral therapy, counseling and pharmacotherapy, as indicated.
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The surgeon should document that the patient understands the benefits and risks of the available surgical and non-surgical management strategies. This documentation also must include an informed decision to proceed with bariatric surgery with an understanding of the surgical risk and the commitment to medical management thereafter.
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A contracted mental health professional must perform a psychological evaluation prior to the surgery to establish the patient's emotional stability, ability to comprehend surgery risks and to give informed consent, and ability to cope with expected postsurgical lifestyle changes and limitations. This consultation may include one unit of psychological testing for personality assessment (for example, the MMPI-2 or the adolescent version, the MMPI-A).
- The physician should arrange follow-up with the patient to monitor for any long-term complications occurring as a results of gastric surgery.
In cases where a revision of the original procedure is planned, documentation of all of the following is required:
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Date and type of previous procedure
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Factors that precipitated failure
- Complications from the previous procedure that affect the patient's inability to maintain the weight loss. If the indication for the revision is a failure of the patient to lose a desired amount of weight, then the patient must meet all of the initial preoperative criteria.
Thank you for the reply.
The surgeon is a good question. I have been in contact with Oregon Weight Loss and the insurance coordinator took all my information and is the first one that said the insurance company will not pay for any of it, even if it is medically necessary. They wouldn't even see me unless it was a private pay basis.
My regular doctor had mentioned a few times about sending me to a cardiologist. I then said I wanted to know how my heart was as well. So he referred me to one. They did an ultrasound and a stress test. The Cardiologist said my heart is in great shape and that he feels the surgery would be a benefit to me and that I was a perfect candidate. He then wrote a letter stating all the things that are wrong and how much this would benefit my health. I don't think this information ever got past the insurance coordinator at Oregon Weight Loss. I did talk with the insurance company and it doesn't sound like it would have made any difference.
I had heard there was a way around this if it was a medical need and not just weight loss surgery. :-(
Thank you again for responding and congrats on your surgery. I am sure it said you had it last month. How are you doing and would you do it again?
HW: 274 | SW: 232 | CW: 137 | Goal: 145 (ticker includes a 42 pound loss pre-op) | Height: 5'4"
M1: -24 (205) | M2: -14 (191) | M3: -11 (180) | M4: -7 (173) | M5: -7 (166) | M6: -8 (158) | M7: -11 (147) | M8: -2 (145) | M9: -3 (142) | M10: -2 (140) | M11: -4 (136) | M12: -2 (134) | M13: -0 (134) | M14: -3 (131) | M15: +4 (135) | M16: +2 (137)
what state do you live in? I'm also just starting the process of trying to get wls, I live in NV and have medicaid/amerigroup
Just starting process of trying to get wls, has anyone actually gotten approved and had surgery in Nevada? I need any help I can get.
Have you hooked up with a surgeon yet? They usually have an insurance coordinator who knows all the ins and outs, and they will submit the paperwork to insurance for you. Once this is done, if it is denied, it will be denied in writing - then you will know the reasons why, and you can appeal.
Alternatively, if you don't have a surgeon yet, I would gather all your letters from your doctors, your medical records showing your BMI for the last 2 years and that your weight is the cause of your diabetes and high blood pressure, and a letter from your PCP or other doctor stating that the surgery is medically necessary to treat your diabetes and high blood pressure. Then, send it all in (make copies!) to your insurance company. They will write back with either an approval or denial, which you can appeal if necessary.
Good luck!
HW: 274 | SW: 232 | CW: 137 | Goal: 145 (ticker includes a 42 pound loss pre-op) | Height: 5'4"
M1: -24 (205) | M2: -14 (191) | M3: -11 (180) | M4: -7 (173) | M5: -7 (166) | M6: -8 (158) | M7: -11 (147) | M8: -2 (145) | M9: -3 (142) | M10: -2 (140) | M11: -4 (136) | M12: -2 (134) | M13: -0 (134) | M14: -3 (131) | M15: +4 (135) | M16: +2 (137)
Hockeymom87 · 0 replies · 727 views
