[msdizzydolores]

I had an appointment with my primary last night. She was busy with other patients so the attending physician who as assisting her from the hospital spent a good amount of time talking to me and going over my health history and he thinks I should have no problems AT ALL because I weigh 313 and my BMI is 52.9...YIKES!

He looked over my records and sees that I have had this weight within 10-12 lbs for over 2 years and the documentation of how both of my doctors have talked with me about losing weight, some methods, etc. I asked him if my undocumented history of the times I have lost (I ONLY GO TO THE DOCTOR IF I AM SICK...I've never gone to tell them I started a diet!!!) weight and gained it back going to hurt me. And I let him know how concerned I was about that because I had so many diets in my life but never did it with a doctor. He said with my aching feet, back, legs, my pre-diabetic state, my high cholesterol, MY PCOS, my GERD, my height and weight and BMI stats, the insurance company HAS TO SEE THIS IS a must for me.

He said he will do whatever he can to advise them from a medical point of view this is necessary for me NOW, because I have been getting worse over the past 2 years and what is ahead will only be worse if I don't do something now. So he said he will write, call or do whatever he has to when they request information from me so I can get this done.

I talked with him about starting ANOTHER miniature diet so it can be on record. He agreed and told me to do nothing major, just lower my caloric and fat intake, some form of exercise and to come back in two weeks...that way it's documented that I am trying and the doctor is supervising it...so I watched what I ate for dinner last night, walked on my treadmill for 5 minutes and this morning I will have some oatmeal and some fruit and I will go from there.

Because of my co-morbs and my BMI being 53 almost, will my lack of a documented 6 month supervised diet be a problem? Am I doing the right thing by requesting to try something again and just have him document it so the insurance company will see I have and am still willing to try?

[PJspeach]

That is going to depend on your insurance requirements. I have bc/bs of Alabama and I was required to do a 6 months dr supervised diet. I just had my last visit this past Monday and was qualified yesterday for surgery. My husband has United Healthcare with the Amtrak Amplan. He only had to show that he had been overweight for the last 5 years and poof.....he was qualifed. HE has been waiting on me for the last 4 months so we can have surgery around the same time. So it varies. Good luck on your journey!

[msdizzydolores]

Thank you Valyn. Good Luck on your upcoming surgery. I have been overweight since I was in 12 grade and before that...but became OBESE probably in my mid 20's.

I had to make sure my file had my weight from a few years ago and I've been close or over 300 lbs forever.

I wonder what Keystone Healthplan East requires? I don't want to call and tip them off

But I will check with the clinic I am going to and I will post a message on their forums.

I am hoping I just have to prove how long I've been obese like your husband...then I am golden.

(((((Hugs))))) GOOD LUCK! And I hope to be joining you on the loser's bench soon.

[Rachael]

You can call them for information and not "tip them off." You don't have to tell them who you are. And even if they don't require a supervised diet for their program (mine requires an up to 6-month case-managed program), it will be good for both you and the surgeon if you do.

But now that I think about it, the "tipping them off" thing is not the right idea. First of all, not only is it your right to know exactly what the cover and how they cover it, you really NEED to know so that you can make sure that you follow their directions to the letter and they can't say you didn't do something.

They should have it outlined in their information and if not, they will be glad to talk with you about it. Again, you really need to know everything they want and require so that you can make sure you give it to them rather than send them stuff only to find out that you need to start all over and/or give them something else.

I was able to find out everything that my insurance company needs both by talking to them on the phone and by looking them up on the internet. I also found another site where someone in my state is insured by the same company and spoke with her. I found out one of the hospitals where my insurance company refers people (I cannot chose my just any surgeon - I can ONLY go to a Bariatric Center of Excellence that they send me to) and talked with them.

It will go a lot faster and easier if you know everything that is required of you up front, less surprises and disappointments too.

[clancythecamper]

I agree, it is your right to have a copy of your policy and from there you can read to your hearts content. You should be able to get a copy from your or your spouses employer. Also, when is the renewal period for your insurance? Ours is in October, but many are Jan 1, be sure that there will be no major changes with insurance carriers or plan provisions. I actually called my insurance to be sure weight loss surgery was a covered bene and ask what they needed. When I went to my surgeon, his coordinator said I could just give what they want, but if I follow their recommendations I was more likely to sail thru. So, I did another 6 mo weight loss with my doc and followed it to the "t". She told me that with some companies, if they dont approve the first time, you may have limited rights to appeal their decision and then you're stuck. This is why it's so important to know what you've got (policy wise). Have you chosen your surgeon yet? gone to any support group meetings? It was very helpful to me to get their input. Also, during my pre-op diet, I really didnt knock myself out but I did start making the lifestyle changes that take time. I honestly am glad I didnt rush it, from the emotional and psychological changes needed, the time for me was well spent. Best wishes

[Rachael]

Originally Posted by clancythecamper

Have you chosen your surgeon yet? gone to any support group meetings?

That is another reason it is important to know how your insurance works. Normally, for anything (orthopedic, opthalmologic, dermatologic, rheumatologic, radiologic, etc.,) I can go to ANY physician I want and my insurance covers it - if they are in their plan, the cover it for even more.

EXCEPT WLS.

First of all, to be eligible, I have to meet certain criteria. IF I do, then I fill out a form and send it to my insurance company. IF, based on this, they accept it, I am accepted into their case-managed program to which I have to follow certain rules, including agree that if I have surgery, I follow up with a their 2-year case-managed program.

I'm sure if I had just gone to a surgeon and they checked my insurance, they would have told me I needed to get with my insurance company, but the point is, some companies have very strict things they want done, or a certain way to do them and you just can't do that if you are going to hide from there. They are not your enemy.

I was told by the hospital that my insurance company was really easy to work with (on their part).

I know some may not be, but the thing is, they want things the way they want them - and they are paying for it. And I try to look at it like they would rather pay for this than pay for my comorbidities - or for me to ignore my comorbidities and have worse problems down the road.

Open enrollment is just about up for me. Actually, that was how I found out my insurance covered WLS. I know a couple years ago they didn't (because I asked because I wanted it then). So with open enrollment coming up (the month of November) I wanted to find a company that covered it (I have several choiced through my work). But it turned out they all covered it, I like mine best and have been with them for 7 years, so why change.

But you need to talk to your insurance company. You need to find out how much they cover, who they cover and what you need to do. There is just no way to do it if you try to hide from them.