Questions???!!!!! - ThinnerTimes

tsunami27 · 07-07-2008, 11:32 AM

So, I have my first appt. w/my surgeon in 1 week. My primary care physician recommended the surgery, my BMI is 40.3, I'm barely 5'4", I have high cholesterol, Type 2 Diabetes, high blood pressure & heart disease all run rampant through my dad's side of the family (I thank god have none of them!!) .......oh - and I have a long history of diet failure...so my question is.....is there a chance I will be denied? I've read on TT about a LOT of people who claim that they didn't even qualify for the surgery but were able to get approved for it anyway. I have PPO insurance, and they are the ones who told me which Dr., etc. to go to.

I REALLY want to have the surgery. I used to be so active! I used to teach Tae Kwon Do & Karate, I used to surf, I used to ride dirt bikes, I used to enjoy DOING, period. I know how much hard work it will be & how strong I need to be, and I know I can do it. I think I kind of freaked myself out about the approval thing though by reading of some other people's misfortunes. Anyone else out there share the fear? I mean how can they possibly deny me? That's all I can think of and I haven't even had the consultation yet!! I'm just so looking forward to waking up & having this tool!!!!

BabyNicole · 07-07-2008, 11:35 AM

It really all depends on your insurance. Some insurances (like Oxford) are VERY easy. Some make you go on a six-month diet; some make you have 5 years of weight loss attempts; some exclude WLS all together!

My suggestion to you is to call your insurance company and inquire about WLS. Write every thing they say including the person's name, date, and time.

You sound to be the same weight and height I was. Good luck!

tsunami27 · 07-07-2008, 11:38 AM

My insurance sent me to one of their "centers of excellence" or some such nonsense....and their verbiage reads "if deemed medically necessary" in regard to WLS. So I think it's the the surgeon who makes the decision?!

I just wish I had a damn answer already, ya know?!! - Oh, and the surgeon doesn't have a long course or anything, but they do have mandatory nutritional classes & a psych exam....a woman in the office said their process usually takes 2-3 months.

BabyNicole · 07-07-2008, 11:42 AM

Quote:

Originally Posted by tsunami27

My insurance sent me to one of their "centers of excellence" or some such nonsense....and their verbiage reads "if deemed medically necessary" in regard to WLS. So I think it's the the surgeon who makes the decision?!

I just wish I had a damn answer already, ya know?!! - Oh, and the surgeon doesn't have a long course or anything, but they do have mandatory nutritional classes & a psych exam....a woman in the office said their process usually takes 2-3 months.

Well, if your company follows the "standards" you should qualify. Even if you didn't have comorbities, your BMI is 40+. So, if I'm correct, all your doc needs to do is deem you fit!

But, that doesn't mean the insurance company doesn't want you to do more. As you can read on here, insurance companies can be a PITA!

My surgeon also required a psych eval and NUT visits.

Tonystark04 · 07-07-2008, 11:51 AM

Quote:

Originally Posted by tsunami27

So, I have my first appt. w/my surgeon in 1 week. My primary care physician recommended the surgery, my BMI is 40.3, I'm barely 5'4", I have high cholesterol, Type 2 Diabetes, high blood pressure & heart disease all run rampant through my dad's side of the family (I thank god have none of them!!) .......oh - and I have a long history of diet failure...so my question is.....is there a chance I will be denied? I've read on TT about a LOT of people who claim that they didn't even qualify for the surgery but were able to get approved for it anyway. I have PPO insurance, and they are the ones who told me which Dr., etc. to go to.

I REALLY want to have the surgery. I used to be so active! I used to teach Tae Kwon Do & Karate, I used to surf, I used to ride dirt bikes, I used to enjoy DOING, period. I know how much hard work it will be & how strong I need to be, and I know I can do it. I think I kind of freaked myself out about the approval thing though by reading of some other people's misfortunes. Anyone else out there share the fear? I mean how can they possibly deny me? That's all I can think of and I haven't even had the consultation yet!! I'm just so looking forward to waking up & having this tool!!!!

Hey Sunshine!...I had that same feeling looking into the surgery...I have no high cholesterol, Type 2 Diabetes, high blood pressure or heart disease, but it's runs fast through my family, and I'm the last one left without it.

And guess what I GOT APPROVED! 2 weeks ago, and I'm 3 days away!!!!

DONT GIVE UP....YOU CAN AND WILL GET THIS DONE!

Shell8170 · 07-07-2008, 03:58 PM

I had exactly the same fears! I am 5'4 and weigh 242 so I am on the low end of meeting the requirements like you weight wise. I have some comorb's like high blood pressure, high cholest., asthma and awful heart burn but I don't have diabetes though there is a family history. I had to go through a 6 month program with the NUT and a million tests but we submitted on June 10th and I was approved on the 27th...my point is hang tight. Do whatever they ask you to do. Have any records submitted to the surgeon of previous efforts, health issues, and letters from docs who may have seen you for your weight. Insurance companies aren't always great to deal with but try your best not to stress over the approval this early on. I know its easier said than done but just find out what your insurance requires from you and go from there...it doesn't really matter what the surgeon requires though you will have to do whatever he says also, just make sure he helps you do all that your insurance requires. Also don't let the dr's office tell you what your insurance requires, make sure you go through your insurance directly to get that info. I have read many stories where the dr. says one thing and people go through that for several months and then realize that their insurance requires something in addition and they end up having to essentially start over...so be weary of that trap.It sounds to me like you qualify health wise but again you need to have a standard from insurance to work with. I wish you the best of luck! I'm scheduled for surgery July 24th so I can't be much help with the surgery part but if you have any questions about the approval process you can message me personally.

Sue0609 · 07-07-2008, 06:28 PM

Are you having your first weigh-in a this appointment? I would wear ankle weights and jeans. My insurance requires a "diagnosis of morbid obesity" (BMI of 40 or higher), nothing else. Some insurances allow a lower BMI if you have a co-morbidity, but most consider only diabetes, sleep apnea, heart disease and high blood pressure to be comorbidities. They don't consider asthma, bad knees, gastric reflux, etc. And they don't care about family history from what I've seen.

Surgeons vary on the way they report weight. Some report the weight you are at after their mandatory diet to the insurance company, some report your first weigh-in weight.

tsunami27 · 07-07-2008, 06:54 PM

Quote:

Originally Posted by Sue0609

I would wear ankle weights and jeans.

Hey, I like this idea!!!

It would be the only time I've ever tried to be fatter!!