[MsVickie]

As most of you know I love asking the question what type of insurance do you have and how much trouble did you have getting it approved.

I thought maybe if I started this thread and kept adding to it, it may help others when they start on the path to this life saving surgery.

What I have noticed in the 3 months I have been posting is most of the criteria that you have to meet from just about all of them that still pay are pretty much the same with just a few differences.

I personally would recommend to anyone to call your insurance company first before visiting any surgeon. You may have a Blue Cross Blue Shield policy but not all will pay for the surgery itself. They go by the group number that is listed on your card and then look to see what type of policy you have. Always write the persons name down.

Most of the criteria is as follows...

Must be at least 100 pounds over weight. From what I gather they go by BMI to get this number.
You have to have at least one Co Morbidity
Examples:

Diabetes
Arthritis
GERD
High Blood Pressure there are others these are just examples.

The federal government insurance plans are probably one of the easiest to be approved on.

Examples of Government Insurance from the United States:

Medicare
Medicaid....state run but will pay in most cases
TRICARE
TRICARE Prime
Blue Cross Blue Shield the Federal Employees Plan Only.

I had TRICARE Standard. I had no problems. I found out the criteria I had to meet first. That give me the greatest tool to work with. You will have to meet it or you will get denied.

It required that I have at least a 2 year medically supervised diet in my records from my Dr's.
That I had been overweight in the past 5 years. that has to be documented in the records from your Dr's that you have seen.

I had to have at least 2 Co Morbidity's along with being at least 100 pounds over weight. I had to have a H-pylori test done to make sure I didn't have a ulcer. Write down within the last 5 years every diet I had tried along with the outcome. Weight watchers is a supervised diet. Never forget to add that to your supervised diet list.
I had to have a Psychiatrist consult. The insurance required one. My surgeon required 2.

When you first get started it will take about 3 months to get to where they are ready to send off all medical records to get approval. It will depend on your insurance company how long they take to get back with a decision. Some are very fast some are over swamped. That is a question you will need to ask when questioning if they pay for Weight loss surgery. How long does it take when you receive records for a answer.

You need to remember that your family Dr has to be in agreement with you to even start a process up to get you even in the surgeons office. If you run across one that wont refer you find yourself another one. Any Dr's records count. It don't have to be just one.

It seems like a battle but if your strong and wanna stick to this......you can overcome.

If your from another country other than the United States you will have a longer wait. But you wont have to deal with our insurance issues.

[DocSanae]

FYI:
The very basic guideline that all insurance companies go by is set by NIH.
The criteria is here, and the original publication stating this guideline is here.
The individual insurance companies and policies may have added requirements, but this is the basic condition that every candidate has to meet.

I am sticking this thread for everyone to see and add.
MsVickie, thanks for starting this.

[Kenyar]

MsVickie, You always come up with the best thread!

I have Empire Blue Cross Blue Shield
I had NO ISSUES getting my sugery approved and EVERYTHING was covered at 100%, even my surgical follow up visits. I've has no co pays regarding this at all thus far which is great because sometimes copays can really add up when you have to see a dr repeatedly.....

When I began my journey, I called the number on the back of the card and asked if "medically necessary weight loss surgery" was covered and they advised yes provided i met certain criteria listed above (see doc's post). I was over 100 lbs overweight, i had 2 comorbidities (asthma and hypertension) and family history of diabetes, hypertension and a laundry list of other stuff. I think because of the 3 things stated, my bmi wasnt an issue. they usually require bmi of 40+ from what i understand. i was at 39 i think but it didnt matter because i had the two illnesses and the 100 lbs.

SO... I went to see the surgeon. They prepared EVERYTHING for me. the only thing i needed was a letter of recommendation from my regular dr. once everything was all in a nice neat little packet, it was sent off the insurance co. for review and i received my approval within that same week.

Everything happend so fast for me. My inquiry, prep, tests (lung function, EKG, Stress test) and approval all happend within 2-3 weeks time. Then my date was literally a few days after the approval came through.

I really feel for those board members who are having issues and who have been struggling (some for months or years) with their insurance. If this is a decision you have made, and feel it necessary to live (literally and figuritively) stick with it.

[fr1endly2]

I have EMPIRE BLUE SHIELD BLUE CROSS - PPO

I had no difficulty.
My surgeons office prepared and took care of it all.
HAD an approval within two weeks of submission after
i had seen all the pre op doctors required and had all
the necessary pre op tests done...!

[MsVickie]

Thanks yall for the post. If we can get a good response to this mabye this would really help out alot of people when they start looking into WLS as a option. Thanks again for your input.

[Chilly]

I have Blue Cross Blue Shield of CA. I went thru a weightloss program called Newstart. They handled everything. I filled out some paper work for them, and they contacted the insurance co to see if they cover it and found out what the insurance co required. It was a VERY easy process. Once I had all the required paperwork in (and required attendace at a seminar) I chose my surgeon thru this program, and went to see him. He reviewed everything and they sent my paperwork to the insurance co. It took about 7 days and I got an approval. Luckily, this program knew exactly what questions to ask the insurance co, and knew exactly what was needed for them. And I'm very lucky that they didn't require much. My "diet history" for the past 5 yrs that I filled out was enough. I didn't have any major health issues. I was over 100 pounds overweight, family history of heart problems, but I didn't have anything. But the reality of it is.....in time you will if you don't get yourself healthy.

[MsVickie]

Chilly it seems like you went though a great program and they did know what they were doing. Thank you so much for sharing that. Im sure it will help someone along the way. Thanks again.

[hav_n_faith]

I also have Empire Blue Cross and my claim was approved with in 24 hours from submission --- what I did was downloaded the criteria from Empires Web site and made sure each and every qualification was satified before sumitting to insurance. It was submitted at 3-4pm and my case worker called me the next day around 9:30 in the morning. It also help that my case worker at blue cross had the surgery too and is 2 years out. She told me to not hesitate to call her---everyone at Empire blue has been great. I had history of back pain, bmi over 35, pulminary overveiw, heart doctor, 3 months of nutritional, a letter from my primary doctor, physc eval, doc to support methods of other attempted fail weight loss programs, ect.

[hav_n_faith]

p.s my surgery is tommorrow---Can't wait

[BOOTS]

Hav N Faith. Welcome To This Board And Good Luck On Your Surgery Tomorrow!! When You Feel Up To It Let Us Know How You Are Doing