Insurance questions - ThinnerTimes

BiGMerf · 06-09-2008, 01:12 PM

Hi im new to the site and figure i can ask a few questions to see if anyone has had the same requirements as me. I am currently 5'10 304lbs with a bmi of 43. i saw the gastro doc this morning and he confirmed that i am a candidate for the surgery.

Now the way i got here goes like this. I was injured at work and now have 2 loose discs in my back that have to be removed and fused. Now i have seen 2 surgeons that have come to the same conclusion.. I cannot have the surgery without first losing 100-125 pounds. Now my condition has kept me out of work for a year already and has severely limited my lifestyle. Some days i cant even walk.My bp is also high along with my cholesterol (not to the point that i need meds though)

So i contact my insurance company and they tell me yes it is covered but only if i can provide some documentations of which i cannot provide like 3. Now she did tell me to put together a medical packet with any documentation as to why i would need the surgery..Letters from surgeons explaining why i need the bypass first in order to get the back surgery.Then they would submit it to see if it would be approved.

Now i know some will say try conventional ways but i believe i have even spent thousands on the over the counter junk and could never loose. Exercising is out of the question since anything that involves my legs or back leads to tremendous pain.Some will say , well dont eat nothing but common is that really likely..

. i have begun a diet in which my cholesterol has dropped 25 points but i gained 2 lbs

..

SO any way what do you guys think? Anyone ever have a special circumstance like mines?

BiGMerf · 06-09-2008, 05:12 PM

im sorry i forgot to ask this question..

i was undr my own insurance up untill march of 08 but was released due to the fact i have been out of work for more than a year due to injury. I have since been added to my wifes insurance (may 08).D o you think that would have a relevance.as far as preexisting etc?

Debz · 06-09-2008, 05:22 PM

Quote:

Originally Posted by BuCwiLd

im sorry i forgot to ask this question..

i was undr my own insurance up untill march of 08 but was released due to the fact i have been out of work for more than a year due to injury. I have since been added to my wifes insurance (may 08).D o you think that would have a relevance.as far as preexisting etc?

As long as there was no lapse in coverage for more than 60 days, I believe it's 60, but I might be off a little)the pre-existing cndition clause shouldn't apply to you. Good luck.

reane1973 · 06-09-2008, 05:27 PM

I Would Say If Your Insurance Co Is Like Mine They Have Guidlines They Have You Follow To Qualify. What Are Their Guidlines? Are You Suppose To Do 6 Mths Dr Documented Dieting? What Do They Require That You Dont Have Proof Of? In Your Surcomstance I Might Think They Will Accept, But They Have Guidlines For A Reason I Guess... And I Dont Know If You Just Joining Your Wifes Insurance If It Will Hurt? Did You Call Her Insurance? Is That The One You Were Talking To? I Wouldnt Call It Prexisting Condition, Cause You Never Did Anything About The Weight For It To Be Prexisting. Probably Wasnt Any Help, But Thought I Would Try...
Renae

BiGMerf · 06-09-2008, 06:01 PM

here are the guidelines they gave me.

1.obesity present for more than 5 years, medical documentation needed.
Now it has existed for way more than 5 years but i moved from Ct to pa 3 years ago. I have med doc. from 06 foward but i hadnt seen the doc prior to that since 2003. so i only have 3 years.i called my previous doc and he said he would search for it but honestly they may be gone due to it being more than 5 years ago

2. bmi of more than 39
check- mines is 43

3.history of failed dieting
I dont have that

4.current medical evalution
check-i can do that

5-document of a co-morbid medical condition
check-high blood pressure, somewhat high cholesterol and of course the risk of paralysis if my disks are not repaired

reane1973 · 06-09-2008, 06:11 PM

Number One>>> Do You Have Anything Or Can Get Anything That Has Your Weight For Five Years? Chiropractor, Dr, Anywhere They Weigh You. Even If You Dont Have Five Years, I Would Try To Submit It. It Sounds Like You Need This Surgery. Does Your Old Dr Have Anything In Your Files? Did You Go Anywhere That Would Have Weighed You. Someone On Here Had Pictures That Has Dates On Them For Some Of Their Five Years, So They Can See Your Weight? And Do They Want You To Prove You Have Dieted And Failed? I Mean Mine Doesnt Require That Other Than My Dr Telling Them I Have Tried Ww, Or Diet Pills Or Any Diets You Have Tried. I Have Tried Them All But Dont Have Any Documentation On Them Except My Dr Telling Them That. I Wonder If That Is What They Mean. How Would You Prove You Tried To Diet? Somethings They Have To Take Your Drs. Word For. Im Sure You Have Tried Something????
Renae

BiGMerf · 06-09-2008, 06:24 PM

Quote:

Originally Posted by reane1973

Number One>>> Do You Have Anything Or Can Get Anything That Has Your Weight For Five Years? Chiropractor, Dr, Anywhere They Weigh You. Even If You Dont Have Five Years, I Would Try To Submit It. It Sounds Like You Need This Surgery. Does Your Old Dr Have Anything In Your Files? Did You Go Anywhere That Would Have Weighed You. Someone On Here Had Pictures That Has Dates On Them For Some Of Their Five Years, So They Can See Your Weight? And Do They Want You To Prove You Have Dieted And Failed? I Mean Mine Doesnt Require That Other Than My Dr Telling Them I Have Tried Ww, Or Diet Pills Or Any Diets You Have Tried. I Have Tried Them All But Dont Have Any Documentation On Them Except My Dr Telling Them That. I Wonder If That Is What They Mean. How Would You Prove You Tried To Diet? Somethings They Have To Take Your Drs. Word For. Im Sure You Have Tried Something????
Renae

brilliant idea i think i may be able to get a hold of some records from a doctor i was seeing 4 years ago for my back... ill try and track those down tomorrow.I have also not given up hope on hearing back from my ex-doctor. I have tried many ways to lose weight, i have wasted thousands on those hydrocut, xenodrine, etc pills along with gym memberships. But all has failed.

reane1973 · 06-09-2008, 06:32 PM

Well I Think You Will Get All Of Your Requirements. Just Think Where You Were And Who Recorded Your Weight. Even The Hospital? Any Proof Of Your Weight Sould Be Good Enough. And Im Sure A History Of Failed Dieting Is Just You Telling Them What You Did And How You Did? I Will Keep You In My Prayers. I Am In The Process Of Getting All Of My Stuff In Order For My Insurance Co. And I Have A Bunch Of Tests This Week And One More Weigh In July 9th Then I Can Submit To The Insurance Co. So I Am Also Holding My Breath Too. I Know How You Feel. Also Just Wanted To Tell You I Am Also From Pa. I Live Somewhat Near Pittsburgh. Nice To Meet Someone Else From Pa. This Site Is Great. I Have Learned Alot From It. Hope You Keep Visiting And Let Us Know If You Get All Of Your Stuff And How It Goes.
Renae

frances · 06-10-2008, 05:34 AM

Quote:

Originally Posted by BuCwiLd

Hi im new to the site and figure i can ask a few questions to see if anyone has had the same requirements as me. I am currently 5'10 304lbs with a bmi of 43. i saw the gastro doc this morning and he confirmed that i am a candidate for the surgery.

Now the way i got here goes like this. I was injured at work and now have 2 loose discs in my back that have to be removed and fused. Now i have seen 2 surgeons that have come to the same conclusion.. I cannot have the surgery without first losing 100-125 pounds. Now my condition has kept me out of work for a year already and has severely limited my lifestyle. Some days i cant even walk.My bp is also high along with my cholesterol (not to the point that i need meds though)

So i contact my insurance company and they tell me yes it is covered but only if i can provide some documentations of which i cannot provide like 3. Now she did tell me to put together a medical packet with any documentation as to why i would need the surgery..Letters from surgeons explaining why i need the bypass first in order to get the back surgery.Then they would submit it to see if it would be approved.

Now i know some will say try conventional ways but i believe i have even spent thousands on the over the counter junk and could never loose. Exercising is out of the question since anything that involves my legs or back leads to tremendous pain.Some will say , well dont eat nothing but common is that really likely..

. i have begun a diet in which my cholesterol has dropped 25 points but i gained 2 lbs

..

SO any way what do you guys think? Anyone ever have a special circumstance like mines?

If you were injured at work this sounds like it would be a worker's compensation claim rather than a private insurance claim. If you require fusion surgery (or whatever back procedure) in order to correct the injury obtained at work, and prior to THAT surgery the surgeons believe you need gastric bypass surgery to lose the weight, then you should be pursuing the WC insurance. Do you have an attorney for your WC case?

I would go that route first because that would seem to remove some of the private insurance obstacles you mention.

Good Luck

BiGMerf · 06-10-2008, 07:22 AM

Quote:

Originally Posted by frances

If you were injured at work this sounds like it would be a worker's compensation claim rather than a private insurance claim. If you require fusion surgery (or whatever back procedure) in order to correct the injury obtained at work, and prior to THAT surgery the surgeons believe you need gastric bypass surgery to lose the weight, then you should be pursuing the WC insurance. Do you have an attorney for your WC case?

I would go that route first because that would seem to remove some of the private insurance obstacles you mention.

Good Luck

i spoke to my wc lawyer and she said that they are required to cover this procedure

. i plan on calling another lawyer though and shopping this case around since i feel that this lawyer is doing nothing for me

****update****

I called workmans comp and was told that wls is not covered