Surgery approval/denial stories

clcesari

Good Morning-

I currently know 4 people in my close circle who want to start the WLS process. I know a couple of them have policies that don't cover it. (Kaiser and BCBS IL.) Did anyone get approved after an appeal with a policy that said it wouldn't cover it? I would love to be able to give them some positive examples. Any suggestions and information would be very helpful!

authorwriter

My husband's BCBS specifically excluded WLS, though it does cover any sequellae relating to WLS. so I called BCBS and got myself an individual plan that covers WLS. It's $550/month, but I think we make that up in the grocery savings alone. I also chose the plan with the lowest deductible/max out of pocket they had. At first, they wouldnt cover a VSG, said they only covered bands and bypass. My surgeon and my primary both got on the horn with their medical director. My surgeon spent a long time with him explaining that the VSG was part of a two-stage procedure that had better results with high-bmi individuals, such as myself. I was topping BMI of 53. I was showing signs of metabolic syndrome. My BP was going up, I was becoming pre-diabetic. she said to him: "Do I have to draw you a picture?"

She had the impression he didn't really understand the advantage of a two-stage procedure, or of going with the VSG first. Less time on the table was a big one, which is far less dangerous for somebody as big as me. also, the opportunity to go on to a DS if I wasn't losing enough with the VSG alone.

next thing I know there's an approval letter arriving in the mail and this after I'd decided I'd have to pay out of pocket because I wanted to follow my surgeon's recommendation of the VSG, not just beg for a bypass because that would be covered.

The up note of having to put out 6600 in insurance is that I met my deductibles and max out of pocket right away (about 4500) and now everything I get is free. That honeymoon period, so you can bet I'm getting everything done I can now, including taking advantage of using all my physical therapy visits to help my train=wreck of a back. so will be good girl and get all my preventative done, also for the year. I'm going back on my husband's insurance at the end of the year.

most important and why things worked out so well for me was I saw my PCP last Oct to ask about WLS and get a checkup - long over due for years - and he started my six month weight loss records then. That was a big factor in speeding up the time between all those preliminary appts and getting the surgery. Tell your friends to visit their PCP now and get on a 'supervised' weight loss program, such as WW. You'll have the WW records for insurance and for your doc and s/he can see you every month and weigh you. I'm fortunate in that my PCP is the best PCP in the world. I say that without equivocation. He's a real rock star and a Marcus Welby type who will go to bat for me when I need it. He's been keeping a close eye on my post-surgery and working hard to help me with my back issues, getting me xrays and an MRI and getting me to the best specialists to get it resolved.

also, my PCP made sure I got every preventative and well-check he could get me before I even saw the surgeon, mammogram and colonoscopy and well-woman check, etc, and bloodwork because the surgeon will want that and it saves time. I also saw my cardiologist for a long overdue visit to get cardiac clearance for the surgery.

so there's plenty your friends can do now to prep for that approval. most important is finding an individual plan that will cover them. the total cost for my hospital stay was almost 30K. I was in the hospital for two or three nights. They did not try to push me out the door. my surgeons fees would have been an additional 6K or so. I already had credits on the deductible by then but even if I hadn't spent dollar one toward the deductible at that point, I'd have been out 11 or 12K versus 36k and maybe pushed out the door before I was well-enough.

And tell your friends to do their darndest with the pre-op dieting. WW is a horrible diet for me because it allows so many carbs, but even so, following it made me aware of portion control again and of making healthy choices, skills your friends will need as they go forward.

i hope this helps. and no, I don't know of a true no-cost way to get this surgery if your work healthplan won't cover it. I weighed the OOP as small price to pay to get to live out the rest of my life without the health problems that go along with obesity and feeling comfortable in my skin.

EDITED TO ADD: Because of the Affordable Care Act, BCBS could not deny me coverage because of my weight. They couldn't charge me extra in premium. I was up front and told them I was looking for a plan that covered WLS. They were fine with that and helped me pick a plan that would cover. It's a new world out there with insurance.

foxymitchell

I have Cigna and live in GA. I had no problems getting approved. It took them about 3 weeks after getting all my paperwork.

clcesari

Foxy Mitchell- Did your plan originally cover it?

Author Writer- Thanks for the info!

lbrown1428

I have blue cross blue shield of Illinois and mine is covered. I am going to end up paying $500-$1,000 maximum out of my pocket depemding on ho3 much of my out of pocket deductible is met and that's it. I just had my surgery 9/12/2014

lbrown1428

Also I didn't purchase this insurance separately it's my husband's company's insurance.

elifusa

Good Morning-

I currently know 4 people in my close circle who want to start the WLS process. I know a couple of them have policies that don't cover it. (Kaiser and BCBS IL.) Did anyone get approved after an appeal with a policy that said it wouldn't cover it? I would love to be able to give them some positive examples. Any suggestions and information would be very helpful!

Clcesari, I have Kaiser and they have their own department specifically for WLS, and it's covered if you have a certain BMI. OF course you do have to pay some money, some for the exams(depending on your plan) and only $500 for the actually surgery. Not sure why your friends couldn't have the surgery through Kaiser.

clcesari

Elifusa- they only cover it with certain BMI and it has to be documented three years at over 40 BMI. My cousin has been at 39.5 for years.....