Finally seeking insurance approval - ThinnerTimes

OsoDelDesierto · 06-08-2007, 07:57 AM

I'm finally done with the three psych eval appointments, so I met with my surgeon again yesterday for a consult before his office submits my case to PacifiCare for approval.

My insurance, which is through Federal Employee Health Benefits (FEHB), covers RNY, but PacifiCare "may" require a six month multidisciplinary weight loss program before it will approve WLS. PacifiCare refused to give me a straight answer on when it does or does not require this (and it was no more forthcoming with my surgeon's office), so we're not sure whether it will be an issue, given my BMI and comorbidities.

To satisfy all or part of that possible requirement, I have been working with the hospital's dietician since late January, meeting with her in person, communicating via email, and sending my detailed food journal to her every week by email (not that I've been good about staying under 2000 calories, but at least I've been good about logging everything I eat). I have been going to the gym pretty regularly to ride the LifeCycle recumbent bike and I provided a computer printout to Dr. Schwartz of all my visits to the gym since late January (I didn't always do three times per week as I should have, but did average about twice per week). I have also attended all of my surgeon's Saturday WLS support group meetings since the beginning of January, going once or twice a month, as they are scheduled.

I met with my PCP in late November to get the referral for WLS (as he had recommended two years ago) and he gave me some additional diet and weight loss materials to use in case PacifiCare required six months of supervised dieting, etc. Dr. Schwartz wants me to schedule another visit to my PCP a.s.a.p. so that I can show PacifiCare that I have been working with him on this issue for more than six months.

We're trying to cover all our bases, but I'm hoping that PacifiCare will just approve me. Two men in my WLS support group (with much lower BMIs than mine) have PacifiCare through the City of Tucson, and they were approved quickly and with no hassles, which gives me hope. On the other hand, the mother-in-law of one of the WLS support group members was telling me at the last meeting that PacifiCare has been bought out by United Health and is now much harder to deal with, in her opinion. Has anyone had any experience with PacifiCare since the merger? If so, please let me know.

So, I get to wait a little longer - my surgeon says we can expect an answer from PacifiCare in two or three weeks and his office will call me when they hear something...

Nette72 · 06-08-2007, 07:59 AM

Great, things seem to be moving right along and hopefully you will get your answer soon. I know the waiting is the hardest part of it all. Best of luck and let us know as soon as you hear something.

TX DEB · 06-09-2007, 11:05 AM

Eric~

Are you a diamondback fan cause you sure seem to have all your bases covered.

Sorry, couldn't resist. That is awesome you have done so much homework. As they say knowledge is power. I hope they approve you without too much hassle.

VanessaSFL · 06-09-2007, 03:42 PM

I have UHC PPO and didn't have one issue what so ever.I never even spoke to them.Called once to see what they require,did it and whala!

I loved UHC PPO,I am in Fl but I would not think that it is too different from state to state...I may be wrong.

Best wishes,sounds like you're on the ball.

LyndasRoom · 06-09-2007, 04:39 PM

I have Pacificare HMO and did have to do a 6 month supervised weight loss plan, checking with my pcp every month...to document that I wasn't losing

I doubt your surgeons office would waste their time submitting if they weren't confident they could get you approved. Mine was about a year ago, right when they were merging...approval was swift. Hope yours is too.