marina

Optima Health will they cover it?

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OK my optima Health care doesnt cover the Gastric Bypass however they said my doctor can write a request letter which I just got Friday and I sent it off today. Im excited but scared of them still saying no. Has anyone had optima cover their gastric bypass? If so did u have to jump through hoops?

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That's Scary :) no one has had Gastric bypass while being insured by Optima health care. Well I will keep everyone updated on how they do things. I dont think insurance companies have the right to deny u if u have medical issues. Now if u are over weight because u eat twinkies and pies all day well that is a different sory I guess :-)

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Well I got a message from my insurance company. I have to call them back tomorrow but she said the letter I mailed in from my doctor cant come from me it has to come from my primary care doctor or my bariatric doctor whoo hoo so I do have a chance. She didnt say no we are not covering it no matter who sends it in! Im excited! Wish me luck Im calling her tomorrow morning.

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Good luck Marina...most time they say it's not covered, unless it's a case of 'medical necessity'..that's determined by your BMI. Obviously your doctor believes you're a candidate. Many times getting approved is simply a matter of jumping through all the hoops that the insurance company puts before you...hopefully you'll know more soon!

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Yes I hope everything goes well...................im excited

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Well I went to my gastric bypass surgeon and we are going to wait until I have my sleep study on the 22nd of march before we send in my information. That way I have another thing on my list ;-) anyways how does an appeal work if they deny? Do u appeal it or do u get a lawyer?

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I have Optima Health and several years ago, I went through a year of preparation for a Gastric Sleeve surgery at Bon Secours Weight Loss Clinic in VB, VA.  I worked very hard to comply with everything and had all the work ups.  I even paid for the rider for Morbid Obesity which cost me over $15,000 extra for my company to have that.  I was denied and my surgery was canceled the day before my surgery.  I was not offered the option to self pay - yep they just cancelled my surgery after even doing the pre-surgery prep the day before.  Optima Health denied me because they said I was only weighed 10 times in 12 months and they wanted me to go for another year in the program.  I was so upset I just wanted to hire a lawyer and I should have.  I still have not lost weight and in fact have weighed much more due to the steroids from my asthma steroids.  The problem is that this insurance company is just out to get your money so try another insurance company if you can.  Change your insurance plan or prepare to hire a lawyer to fight for you.  Still fat at 310 and miserable with Optima Health.  I had everything done, including a ph test for my stomach to make sure I could do it with my GERD, a barium test, colonoscopy, and a whole bunch of other stuff including several appointments with a nutritionist and psych evaluation which was required - this was a whole year of preparation.  It's ridiculous what I went through only to be disappointed with my miserable insurance company.  My husband and I make good money and we were not even offered the option to self pay which just blows me away.  Still disappointed.

Edited by Kimmibear

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@Kimmibear Really sorry to hear this. What a miserable way to be treated. Plus at this point there is little scientific doubt that bariatric surgery is a SOLUTION that will improve your health and lifespan. 

With all due respect to the diversity of views on this issue, I think it would be great if health care - and in particular insurance - was driven by doing the right thing for you and not just the profit motive. 

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The strange thing is, why would they pay for all the work up and then not support me through the actual surgery. Optima Health does seem to care only about profit.  Not the patient.  All of my weight despite contributing it to my own health was influenced heavily by medication use.  After two children, I only weighed about 135 lbs..  First I gained weight from antidepressants due to childhood abuse.  I gained 150 on those.  The first year of antidepressants I gained 100 lbs.  I asked my doctor what was going on, he said oh it's a side effect of the medication.  I tried some others.  I gained another 50.  Then finally after years of therapy so I could sleep peacefully, I went off of the meds.  I just wanted to sleep at night and not thinking of my dad coming to beat me while I was sleeping or think of him coming to beat me in the shower until my lips popped open.  I wanted to forget other gross memories and be able to cope.  In addition I suffer from moderate asthma so that too requires medication that affects my weight.  As I got older I also required steroid shots in my hips and feet.  Probably more likely those pains in my hips were needed from my already difficult weight in the 270s causing other health problems.  Now after a bout of pneumonia I blew up like 30 pounds from all the steroids they used to save my life.  So losing weight for me even though I don't eat much it's really hard to lose weight while trying to keep breathing.  So I have decided to move to a less humid state.  After I move I will have new insurance and will try again, if I can't do it then, I will self pay!  Hopefully some of the weight will come off as I remove the steroids if my lungs work better in the drier environment.  I had a friend who worked for Sentara out here, I recognized she was at a unhealthy weight and lifestyle.  I asked her if she wanted to join me in the weight loss journey.  The difference was, she got her surgery and lost over 100 lbs. and I am still stuck in the rut of obesity.  I do hold my weight well, still look ok, and I have been given mostly good health reports but I have GERD, ASTHMA, HIGH BLOOD PRESSURE, SCIATICA, VENUS INSUFFICIENCY(with swelling feet), SPONDYLOLISTHESIS, SLEEP APNEA, etc. and this weight is making me very UNHAPPY.  So why the heck won't they help me?  I even get rashes from my belly and have to fight to keep from getting infected from my baby belly and the weight.  Are none of these enough health issues that Optima Health would help me after 16 years of paying 1600 to 2000 a month?  I am getting rid of Optima soon and will never support them again.  I would never recommend them.  Thanks for listening and for the support!

Edited by Kimmibear

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Welcome!  

Just an idea... we have several here who have gone to Mexico for wls with good results.  I had a 6 month program with monthly appointments and was told up front I could not miss a month.  That I also could not gain weight.  

Know before you begin what is required by both your insurance and the bariatric center.  Document each requirement.  

 

Edited by Cheesehead

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