I am probaby putting myself in a bad place here but I am gonna give some information that I thought may be helpful to those of you who have not yet been approved by your insurance companies. I am a registered nurse and just banded on 4/28. I also work for an insurance company in the pre-certification area. I have worked for 2 different companies and have found from both that the criteria seems to be similar. Believe it or not, and I am sure most of you won't, the insurance company is not against you having the surgery. They do however want you to be successful and s such they do usually have some strict guidelines.
First you have to meet weight requirements that are set by the National Institute of Health, not by the insurance companies themselves. For most companies (and some still only cover he gastric bypass, and do not find the lap band acceptable) they require you to have a BMI of 40 or more or 35 or more with SIGNIFICANT comorbidities. SIGNIFICANT comorbidities include uncontrolled diabetes, uncntrolled hypertension or heart or lung disorders that are adversly affected by being overweight. Your insurance company should be able to give you a full list of the conditions that they consider to be significant conditions.
Next companies require that you are involved with a multidisciplinary plan. The reason for this is that they want to know that the doctor that performs your surgery is skilled in the procedure and has been successful with the surgeries in the past. Then they require that you have had nutrition and psychiaric evals to ensure that you are prepared emotionally and diet wise for the significant changes that you will be undergoing after surgery. Yes, most of us have some level of depression but if you are feeling suicidal or you have problems relating to reality you would need to get this treated before considering surgery.
Next is the weight loss pre-op. Many people question why they must lose weight before surgery when it haas been the inability to lose weight that has brought them to this point. Well, there are a couple reasons for this. First the pre=op diet varies from doctor to doctor but in general they want to see that you can handle significant changes in your eating prior to surgery. Next they need to shrink your liver and other organs that may be in front of your stomach so thy can see your stomach clearly for your surgery. Then of course, the fact that we are all obese going in we are significant surgical risks and weight loss does help lesson the risk of complications following our surgeries.
Some companies have upper limits of BMI for the lap band and that is based on the fact that studies have shown that people who are very large do better with the bypass.
All companies are required to provide you with the criteria they use to make a determination so if you are in doubt call your member services and ask for their bariatric surgery criteria. They can give this to you so you know exactly what is required and you can be sure you have done all you need to do before submitting your case for approval. If you have met all the criteria and you are denied then appealing the decision is your best option. The company does need to provide you with a rationale as to why you are denied and if you can prove that their reason is false then you should have no problem getting a denial overturned.
I hope this helps. Good luck to all,
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