Updated: Insurance requirements with questions

mschaffer66 · 01-15-2008, 11:30 AM

Today I go in for my consultation with Dr. Zeni at St. Mary's in Livonia.

I just got off the phone with my insurance company and they said the surgery is covered if you are one of the following:
BMI>35 with comorbid
BMI>40 with 6 months doctor assist diet
BMI>50

I fit in the second category, but don't have the doctor assisted dieting. Does anyone know how to go about getting around the diet stuff? I'm not sure why they even require it...its not like my doc is going to come home and sit next to me at dinner at physically shove me away from the table when he says I've had enough.

What classifies as a comorbid? Is my excruciating back and knee pain in that category? In past doctor visits I've had higher cholesterol and last time had higher blood pressure, do those apply?

I'm kinda lost with some of this stuff. Any advice would be great because I really don't feel like wasting 6 months worth of copays just to be back in this same spot again.

Thanks in advance.

PATCHELTON · 01-15-2008, 12:11 PM

I am waiting for a surgery date and have just finished my 6 month supervised weight loss "diet" which is required by many if not all insurances. Every office does it differently. I met with the dietician from the bariatric team to start the diet. Check with your surgeon's office and see if they offer that. It is really a Catch 22 thing though. When I finished talking to the dietician she told me she didn't care if I lost any weight, but I shouldn't gain any more. I lost maybe 10 pounds, but I didn't rigorously diet. The problem is, if you are successful the insurance company may deny coverage of your surgery, saying you can lose on your own. But the bariatric team wants to do the procedure, which is why they don't particularly want you to lose much if any weight during the 6 months.

As for comorbidities, the list includes high blood pressure, high cholesterol, diabetes, sleep apnea, arthritis, reflux, pretty much any ailment that is affected adversely by excess weight. My BMI is around 37/38 but I have everything on the list but diabetes. My surgeon also said my elevated liver enzymes (on cholesterol test) may also be due to fatty liver disease which can become non-alcoholic cirrohsis, so he plans to take a sample for a liver biopsy when he puts in the Lap Band. I am chomping at the bit, wishing my date was tomorrow. Now I am waiting for the letter from the dietician which comes to me, and I have to take it to my PCP for sign-off, then get it back to the bariatric team, at which point my paperwork goes into the insurance for approval. I weighed 252 at the beginning, and now around 240-241. Not bad for hardly trying. I did have two bouts of strep throat which probably knocked off 5 pounds, since it is hard to eat and I had lots of chicken soup and sugar-free popsicles. So, there you have it. Hope I answered your questions.

babygrl1234 · 01-16-2008, 05:04 AM

If I recall you have BCBS correct? For my diet I had to have 12 months of a doctor supervised diet (last year before they changed their requirements). I had 4 visits in which we discussed weight loss and that was enough to get me qualified. How many visits do you need in those 6 month? Is it monthly? Bimonthly? How often have you been to the doctor this past year? Worst case senario you are 6 months away from surgery.

mschaffer66 · 01-16-2008, 06:31 AM

Went to my consultation last night and like you say worst case it is 6 months out. They are checking with my doctor to see what he has documented.

Miexquizit41 · 02-05-2008, 11:22 AM

I am new here and want to thank everyone in advance for patience as I am not sure about anything. I have a BMI of over 40 and many many health issues that make a Lap Band a viable option.

The problem for the past year or so hasa been my PCP who honestly told me he wouldnt recommend it "because when it doesnt go well, he gets blamed so he will only recommend diet and exercise". I wanted to smack him but realize to start over with a new PCP will just make this take longer so I humoured him and he finally caved in a year later. My OB/GYN and Cardiologist both have been on board with this for a while now.

I have BCBS PPO and am wondering about peoples general experiences with the insurances and what I have to do to get this ball truly rolling. Any help and assistance will be greatly appreciated!

Thanks
Jennifer

kirajh · 02-05-2008, 07:15 PM

mschaffer, You mentioned diet drugs in another post that you had to stop taking cause of problems. If they were prescription, you had to have gotten it from a doctor or even Medical Weight Loss Centers. This would be considered a diet program.

babygrl1234 · 02-06-2008, 08:16 AM

Is it BCSB of Michigan? If so you need 6 months diet documentation. This could be as little as 3 times in the six months that your docotor doculented talking about diet and excersie with you. You need to go to some seminars at your local hospital(s) of choice to find out what they require of you. BCBS of Michigan is one of the better insurances to have for bariatric jsut so long as you don't have an exclusion of surgery inyour specific policy.

Good luck!

kirajh · 02-06-2008, 10:53 AM

Depends on your BC plan. I have BCBS throu Teamsters and it's been over a year since they required a diet plan.

mae · 02-20-2008, 08:47 PM

I have been getting monthly appts with my doctor since last April, 07 to comply with the 12 month visits requirement from BCBS PPO of Michigan.
Yesterday, I found out that now only 6 month visits are required.
I am ready for a May surgery anyways.

PATCHELTON · 02-22-2008, 04:47 PM

I have Carefirst Blue Choice (Maryland) and they required 6 month (or 2 3-month) documented weight loss attempts. I met with the bariatric dietician and we discussed food choices, she weighed me, and then from that point all I had to do was email her my weight every other week, being careful not to miss a weigh-in (they could make you start over). At the end she wrote a letter and sent me two copies of the letter and the documented weights. I had one for my records and one I had to take to my PCP to have her sign off, and then send it back to the bariatric office. The surgeon asked for a stress test, and my PCP sent me for that plus an echocardiogram (I work for cardiologists so I had them done at work and they write off whatever the insurance doesn't cover as an employee benefit). My paperwork was submitted 1/28 and now I am just waiting for approval. I was hoping it wouldn't take this long, but whatever, as long as they say ok and pay for it.

Blund · 03-10-2008, 01:00 PM

All BC's are seperate with their own criteria. I have BC of California (but live in Michigan) and just got approved (in 5 days!) My policy didn't actually state requiring the 6 moth diet, but I had my old WW card from a year ago with a 9 month history which was sent in. I also typed up a history of my last 25 years' struggle with weight loss, and a letter as to why I want the surgery. I assume all of that went in to BC, but I don't know for sure. Maybe you could produce a written journal of some kind? Or a weigh-in history with WW or somewhere else if you tried that?

It sounds like your policy requires a 'pre-service review" like mine. There is a seperate phone number (at least for me) to call them. They have been very nice to me so far. I wouldn't rely on the surgeon's office, you should check this out for yourself. Then you can ask questions about co-payments, etc.

Good Luck.

sstasevich · 03-10-2008, 01:06 PM

Ins. Requirements:
Wether you have 6, or 12 months the key things are 1. get weighed every time,
2. make sure you arange at least 1 visit to a Dr. a month.
You can see your family Dr. this month/get weighed.. Go see your Surgeon next month/get weighed, and the month after, maybe a Cardio.
again get weighed. As long a B.C.B.S. sees the attempt, and you keep going to your Dr. . Its fine! You will rack up 6 months in a row before you no it.Also, you will be taking care of every one you need to see, "shrink included" tell them you must be weighed!!! They will understand what you are doing. Buttt. If you miss any aptmnt. you start counting all over again.
I did mine threw Henry Fords Hospital, and they taught me how to play the Ins. game.. You will see, time will go buy. I had 12 months, and trust me they kept me busy. Get yourself a folder to start a file. Every time you go to a Dr./get weighed, tell them to give you a print out of the vist, put it in the file..
When you have what you need, just take the file with you to the hospital and the Ins. people will do the rest. Hope it helps.. Good Luck, Keep the chin up. It'll happen before you no it. Shirley...

Blund · 03-10-2008, 01:12 PM

All BC's are seperate with their own criteria. I have BC of California (but live in Michigan) and just got approved (in 5 days!) My policy didn't actually state requiring the 6 moth diet, but I had my old WW card from a year ago with a 9 month history which was sent in. I also typed up a history of my last 25 years' struggle with weight loss, and a letter as to why I want the surgery. I assume all of that went in to BC, but I don't know for sure. Maybe you could produce a written journal of some kind? Or a weigh-in history with WW or somewhere else if you tried that?

It sounds like your policy requires a 'pre-service review" like mine. There is a seperate phone number (at least for me) to call them. They have been very nice to me so far. I wouldn't rely on the surgeon's office, you should check this out for yourself. Then you can ask questions about co-payments, etc.

Good Luck.