Originally Posted by Band_Groupie

I think I read all the posts here, so I'll tell you what I've learned (I go for my 5th PCP visit on Monday). I messed myself up at the beginning not knowing all of this and lost two months that I had to begin again. This is probably way more info. than you need, but if it helps someone...
- If you haven't already, call your ins. co. and get a copy of your bariatric policy so you know their rules. Most can show you how to download it online even, or they can send it to you (you have a right to a copy).

The rest of these apply to my case and what I've seen from others, but your ins. may be different:
- Personally, I've found the insurance person at my surgeon's office to be the best source of information since she deals with my ins. co. all the time. Call that person with a list of your questions...ie. your ins. co. will never tell you or spell out in their policy that they expect you not to lose below the minimum BMI, and the ins. expert at your surgeon's office can't legally tell you that either, so word your questions carefully and listen to what they DO say...mine said "If you fall below the minimum 35 BMI then you wouldn't need the surgery would you?" I let her know I got it and she was visably relieved (I've seen lots of posts where people don't get it).
- Make sure you're well over the min. BMI you need (35 or 40) at your first weigh in (I learned this the hard way and had to start over...was 1 pound below). Eat a big meal, wear heavy layered clothing, drink water until you're ready to burst, wear your cell phone and put your wallet in your pocket (like men do).
- Get a seperate form from you surgeon to use at the PCP visits. The surgeon should have a sample to use, if not let me know. You'll turn all these seperate forms into the surgeon along with the PCP letter of 'medical necessity'. I have my PCP keep a copy and I take the original and fax it to my surgeon's office. Not keeping this on a seperate form is risky as the regular 'Doctors notes' that they keep in your file may not be enough or they might forget to note something as simple as your weight that mo. I've seen people denied for their Dr's. notes being incomplete even one mo.
- The monthly visits also have to include doctors notes on EXERCISE program. This gets a lot of people denied. Just have them make a note on what they've asked you to do (ie. 30 min 4x a week) and how well you did with exercise last mo.
- Make sure you know if you are allowed to fall below the minimum (35 or 40) BMI during your 6 mo. (see second bullet point above). None of the three hospitals I intitially looked at wanted you to lose more than a few 5-10 pounds and not go below your min. BMI. I can only lose 10 pounds or I'll be below the 35 min. I've seen so many complain about how counter-intuitive this is (I did too), but some people have to go through so much more than 'not losing weight' to get ins. approval that it's laughable to complain about this. It's a stupid rule, but if it will get you ins. coverage, it's a small issue. I should say that I've seen some ins. co.'s that want to see a certain % of weight loss and they do want you to succeed. Those stories are less common, and I'm not sure even then if you can go below your min. BMI.
- If you're in the 35-40 BMI and need comorbidities make sure you understand how many you need, which ones 'count' and which ones just 'help your case', and what makes them count or not. For most people's ins. the only ones that count are Type 2 Diabetes, High Cholesterol, High Blood Pressure, Sleep Apnea, and Obesity related Heart Issues (there are a few rare conditions like certain obesity related cancers, brain pressure disorder, that MAY count). You have to show TREATMENT for these to count (ie. you are on meds for High Blood Pressure, CPAP nightly for sleep apenea). The other comorbidities just help your case but don't get you a check mark for your requirements (ie. I also have Adult onset Asthma, Osteoarthritis, Stress Incontinence and none of these count).
-The 6 mo. diet has to be 6 CONSECUTIVE months within 2 years of your surgery date. I've rarely seen people get Weight Watcher info. through, but it's rare (seems to be in CA). I've seen people denied for missing 1 visit and even someone denied for having too many days between visits.
- Make sure the PCP visits are CODED to the ins. co. as a WLS weigh in visit ONLY. Do NOT combine this visit with anything else (saw someone denied for one visit being coded as a sick visit...which she was sick, but ins. co. can see the codes and she didn't have a weight visit that mo.).
- Know "How long 6 mo." is. Sounds stupid, but do you need a full six mo., which would be 7 PCP visits including the initial weigh in, or do you need 6 VISITS (I found out half-way through that I only need 6 PCP visits- 1 each month, so it's really only 5 full months. Be careful, some ins. co.'s want 7 visits).
- Some need a weight history (showing you're over the BMI) longer than the 6 mo., I did not (some ins. want 2 years, some 5).
- Make sure all those other pre-op testing/visits (Psych, NUT, heart, Pulmonary, etc.) you do are within 6 mo. of your SURGERY DATE. For most ins., any more than 6 mo. out and you'll have to re-do them. Many people are anxious to get started and do some of these too early. Remember, after your 6 mo. you have to include the approval process and then estimate your surgery date before you start these visits (I waited 2+ months before starting).


Good luck all, and let me know if you have any questions about the above! -BG

Originally Posted by Ms. Readytobehealthy

SPARKLES I must say I am sooooo jealous and HAPPY for you. I am really hoping that it goes through. This way you can share all of the do's and don'ts with all of us. I will keep praying for ya!!

Originally Posted by messiejessie

Hello everyone, this seems like it will be a very helpful thread. That is really great information, thank you so much for compiling it. I’m not sure if it would be better to talk to her before or after the informational seminar. Any advice??

Originally Posted by Tess

Wow I though it was just quite. . I haven't been getting my post notice in the mail what up with that? Well today was my big day. I met with the nutritionist. Officially started my 6 month supervised diet. Met with the Physical therapist and had my phyc eval all in one day. It all went really well. I had to set and talk to that shrink for an hour and a half I think. She ask me everything under the sun but was very nice. I think I did well though. She said I sounded well grounded. Well see

Originally Posted by deputymauldin

Good Luck Tess
So today I realized that I have an HMO and a PPO. This means I don't need a referral. I am calling the WLS office tomorrow to schedule my initial consultation. I'm getting excited.

Originally Posted by messiejessie

Hi! I just got off the phone with my insurance company, Health Partners, and I was very happily surprised that their requirements do not seem very complicated and at least on paper there seems to be a minimal number of hoops to jump through. They require two years documented history of BMI over 40 (which I definitely have) the mental health evaluation, meeting with a dietician, participation in an appropriate exercise program, five sessions in something entitled "HealthPartners’ A Call to Change…Healthy Lifestyles, Healthy Weight® - Weight Loss Surgery Edition" and documentation by the surgeon that I understand the risks involved. The surgery will be covered 90% and my total out of pocket maximum would be $2000 including the all office visit co-pays. The co-pays for the surgeon will be $20 and the dietician will be either $20 or $30. Not too shabby. My informational meeting is next Thursday so hopefully this ball can get rolling quickly.

Originally Posted by Sparkles

Originally Posted by justroni

The rest of these apply to my case and what I've seen from others, but your ins. may be different:
- Personally, I've found the insurance person at my surgeon's office to be the best source of information since she deals with my ins. co. all the time. Call that person with a list of your questions...ie. your ins. co. will never tell you or spell out in their policy that they expect you not to lose below the minimum BMI, and the ins. expert at your surgeon's office can't legally tell you that either, so word your questions carefully and listen to what they DO say...mine said "If you fall below the minimum 35 BMI then you wouldn't need the surgery would you?" I let her know I got it and she was visably relieved (I've seen lots of posts where people don't get it).

This is some great information. My surgeons office requires us to attend 2 pre-op support groups twice a month. They have different people that speak at the meetings such as the staff psychologist, dietitian, people that have had the surgery done called a role model, and they have a meeting called surgery 101 that describes what is going to happen from the day before surgery until you come home from hospital. I thought the 6 month diet history...meant diet and try to lose weight. I had lost 4 lbs one week, and one of my support group buddies informed me I needed to slow up. I sent an email to one of the counselors at the surgeons office and ask her about it. She send an email back and said the 6 month history is really just showing that you can't lose the weight. I was told that if I drop weight every time the insurance company could deny me saying I could lose the weight without the surgery. I was advised not to lose over 10 pounds until after I got my insurance approval. Four weeks before my surgery date I will be on a liquid diet, and have to attend nutrition classes, and have a weight loss goal that I have to meet.