[Andrea45]

Im just getting started in my weight loss journey. I want to get approved for Gastric Bypass. I have BCBS of MA & I was wondering if anyone can tell me if its up to ME to understand all the medical criteria to get approved for the surgery. OR, is it up to my primary care Dr. to understand & tell me what I will need to know, as far as what my insurance company will require of me?? I have my first Dr visit in a few day's with my primary care Dr. & Im hoping that once I show her the data that I got off my health insurance website, that she will tell me exactly what I need to do to qualify. Insurance companys can be difficult to deal with & understand all their medical jargon. And when I called them recently, they basically just read from the internet, what I already had available to me. And im not really sure I really want to understand it! At least this way, if my Dr is getting together all the necessary steps that I need to take, it will be documented & if any issue's come up, I can at least have it all in writing, to show my health ins co.

[Trulykath]

If you go to a reputable weight loss surgeon, they are usually VERY skilled at getting this by the insurance companies. You may have to pony up some past medical records etc....but the surgeon's office usually has a coordinator that knows EXACTLY how to get things approved with each carrier.

I don't have any more advice than that...I was self-pay....I'm sure others will be along and may have experience with your carrier! Congrats on starting your journey!

[DocSanae]

The best bet about knowing what you need is an experienced bariatric center/surgeon's office, actually, as they are the ones who deal with all the different insurance requirements, and often will set up the various appointments you need to fullfil the requirements within their practice. If your PCP is familiar with WLS--has many post op patients in her care--the she may know, but if she doesn't have many WLS post ops, then she may not be familiar enough with the requirements.

[ragdolldude]

My doctor had to provide a referral to my approval for RNY surgery. My insuracne company provides and "outsourced surgeon" for the RNY procedure in my area in most cases. I was very happy with the surgeon, Dr. David Suh, as he has a very good reputation and is also a board certified surgeon. My GP doc went over the guidelines to make sure I qualified and then provided a letter stating so to the insurance group office. They make the final approval for those who get into the RNY procedure within my insuarance group, as my am a member of an HMO insurance group. My surgeon also provides 4 support groups within 40 miles of my home, so that any of his patients have a well established support system to help them with issues that may arise during wt loss. DAVE

[Andrea45]

Thanks everyone, that helps a lot

[not quite Barbie]

My advice is to learn as much as you can and stay on top of the paperwork. THe bariatric center may turn out to be wonderful and do it all for you, but then again - they may just let your paperwork sit around and do nothing until you call them.

The more you know about WLS the better. Many insurance companies require that you've done 6 months of a supervised weight loss program - Weight watchers, Jenny Craig, Atkin's diet with your doctor tracking you, whatever. So if that's a requirement, that's where you need to start. If you can't document 6 months, then you're going to have to do a 6 month diet with your PCP following your progress.

Next, your PCP needs to put this in a letter, also mentioning any weight related conditions (high blood pressure, sleep apnia, breathing disorders, cardiac problems) and that he recommends you for WLS surgery. That will go to the surgeon's office.

They will take it from there and get you all the tests you need. Many of these are to try to find out what co-morbidities you have that you didn't know about - like sleep apnia, and also to make sure you are fit for surgery.

It can be a long road, but it's worth it. Good luck!

PS: most insurance companies will pay if you have a BMI of 40 or more (which you do), but some have additional requirements on top of that.

[Andrea45]

We'll, I just saw my primary care Dr. & it was pretty much an unnecessary apt..she said that once I see the surgeon, the surgeon puts together all the paperwork for you, because they know exactly what the insurance co requires & needs..which is what I thought, but it was nice to see her anyway & at least get weighed & measured. My BMI is about 42, so I qualify & don't need to have any co-morbidities..although Im pretty sure I have sleep apnea...still waiting for the results from that. I did the sleep study because I thought it would be a nice addition to give to the insurance co to help me qualify..the more ammo the better! The Bariatric surgery center that im going to go to is a center of excellence, so i feel pretty confident that they know what their doing & will help guide me in the right direction. Im signed up for a seminar with them for 9/30/08 & will fill out an application at that time. Cany anyone tell me how much weight you all had to loose in order to have your surgery? im 223 lbs & im hoping they don't require me to loose 30lbs...I might as well not do the surgery then, if im already a third of the way there!