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New here and have insurance questions

L

lisabrm

New Member
Hi! My husband and I have both just decided to have the sleeve surgery. So, we're in the process of getting our ducks in a row and making sure we do everything we need to get our insurance approval.

If you had to do a 6 month supervised weight loss plan prior to surgery, how often did you go to your doctor for weigh-ins? We have Aetna and I can't get a straight answer. The policy just says "substantial face-to-face component" but they won't clarify it for me. Are monthly weigh-ins appropriate or does it need to be bi-weekly.

Also, if your insurance required a supervised exercise program with a personal trainer (Aetna has a 3 month approval process with the addition of a trainer), how often did you need to work out with the trainer? Again, no straight answer on this.

I just want to make sure we dot all of our i's and cross all of our t's so they don't deny us at the end.

Thank you so much!!
Lisa
 
Hi Lisa,

I don't know where you are located but I have one suggestion. You and your husband need to attend one of those free weight loss seminars at a reliable Bariatric Surgery Center. I did and I got all that information from the seminar I went to. They took my insurance info at that time and them emailed me with the requirements. As it turned out I knew slightly more than they did and my copays were less than they said. (I ended up making some different decisions though that worked better for me and they worked with me on that) The info included what the weight loss program included and how often you had to see the weight loss doctor. Also you do have to have a referral from your regular physician. Insurance companies often won't talk to the patient, and the people in the insurance office at the Center are very used to dealing with the insurance companies and what the requirements are like the BMI, co-morbidities, weight loss trials, any pre- testing that has to be done. The seminar is the place to start. Joy
 
Welcome Lisa, Congratulations on you and your husbands desision to have WLS. Joy is right, if you haven't gone to seminar yet you two should go. I started by talking to my primary doctor and she gave me a referal to the seminar and from thjer everything worked pretty smooth. Good luck and let us know how you guys are doing. :cool: Tom
 
Yep, I agree...part of the decision to have any of the surgeries is based on the recommendation of your Doctor. If you still haven't spoken to your Doctor about your decision, I would suggest you start there. They will be able to refer you to a Bariatric program that is right for you and comes recommended by your Doctor. Once there, the Bariatric team will help you go through the process and advise you of your insurance's requirements for approval. Good Luck!
 
Welcome Lisa and Lisa's husband. After I attended the seminar by the bariatric surgeons, they suggested calling the insurance company to find out if they covered bariatric surgery and the requirements. The only useful information I got was that they did cover bariatric surgery. I wouldn't get too stressed about the insurance company not giving you information up front. The people who answer the phones are not the same people who will put the rubber stamp on the procedure. I found the office staff at the surgeon's office to be much better informed since they work with insurance all day every day. That is still not a guarantee that you will sail through the process, but it is a start. Good luck to you. How nice that you both can go through this together.
 
About your question on weigh-in's. I have to weigh before each of my dietary consults (6), and they require 5 years of weight history from my primary care doctor. Easy enough to get since I've been going to the same PCP for over 10 years. Cigna also counts the first visit to the surgeon as a dietary consult. At first I thought this was cheating (just can't get the Catholic guilt out of the girl) but realized that I picked up several good tips from the staff and the dr. at this first meeting.
 
Lisa-Welcome to the forum and congratulations on deciding to have WLS. I see that the replies to your questions provide a lot of great information. The only other thing I can add is to actually select a surgeon and arrange for a consult. Once you do this the staff, usually an insurance coordinator, will find out EXACTLY what you need to do to get insurance approval. Trust me when I say they will rattle their cage if needed. You shouldn't be the one running around trying to find answers because there is too much at risk if even one requirement is not met to the fullest extent.

Make sure to come back to the forum to let us know how things are going for you and your hubby :) :) :)
 
I just recently saw the surgeon with regard to the surgery. Within 3 weeks, I'll see the nutritionist. The girl who handles the insurance says I'll probably have the surgery by the end of October. Is it possible for things to happen that quickly? I've heard all kinds of stories where it takes 6 months or longer. I have Medicare for my primary insurance. If it can happen that quickly, it'll tickle me to death. I'm ready right now and can't wait til it's done, so I can start losing weight (FINALLY).
 
Hi Barbara J, yes it can happen that quickly, some insurance companies and medicare programs require supervised diets and exercise plans and some dont, I think from seminar to surgery it took about 3 months for me, I had Blus Cross. Good luck. :cool: Tom
 
I think the plans are different, but I have gotten good information from my Dr.'s "concierge" or nurse. She hasn't said anything about exercise but 1. I can't afford it and 2. I am suffering with back problem, heel spurs, plantar fasciitis, and a shin splint. I saw a nutritionist before I even thought of the sleeve over the summer for about 4-5 months and the nurse is hoping that they will count that or that they will bridge my treatments. I would have to wait 6 more months. I am also waiting for approval to have a sleep study done. So much waiting. Once I make a decision, I like to act upon it!
 
mem222 said:
I think the plans are different, but I have gotten good information from my Dr.'s "concierge" or nurse. She hasn't said anything about exercise but 1. I can't afford it and 2. I am suffering with back problem, heel spurs, plantar fasciitis, and a shin splint. I saw a nutritionist before I even thought of the sleeve over the summer for about 4-5 months and the nurse is hoping that they will count that or that they will bridge my treatments. I would have to wait 6 more months. I am also waiting for approval to have a sleep study done. So much waiting. Once I make a decision, I like to act upon it!
Click to expand...

Gee I was wondering who updated a post that is almost 2 years old. Now I understand.

I hope to see you posting elsewhere. We are all here to help each other out.

I was fortunate. I didn't have to go through the 6 month program. I hear there are insurance companies that do require this.

If you post your question, with all your specifics in your profile, folks will be able to work with you more easily.

I did go through the sleep study. I knew I had sleep apnea. I was on a machine already for sleep apnea but I had to go anyway; it was a waste of time. The sleep doctor changed my number slightly on my machine. Then as soon as the surgery was over, I had to have the number reduced drastically since the pressure very quickly became too much. This is a result of the rapid weight loss that does occur in the first month as well as the positive air pressure of my CPAP machine was making me very uncomfortable since it was blowing right into my new small stomach.

At this point, I no longer need the machine. From my point of view my sleep apnea is gone. So I don't use the machine anymore. I will go through a formal test later this year.

As you have read in this thread, you should have gone to a weight loss seminar by now. Pick a good doctor that has a good ranking in the bariatric community. He should be in "best doctors" for your region. Pick a good hospital as well. The hospital should be a "bariatric center of excellence".

Your doctor's staff will help you navigate through all the tests, conditions, approvals with your insurance company that is required. They are experienced and no how to do it and gain approval.

Best wishes,

Ralph
 
Welcome to the forum to both you and your husband. It is so awesome that you can both go through this journey together. I got a referral from my PCP to the Bariatric center that I am going through. Once I started going there the staff took over as far as insurace is concerned. Their staff made all of the appointments and everything.
Hope this helps some. Start with your Primary then have him/her refer you and your hubby then off to the bariatric clinic. Good luck

TillieS
 
hi, im nervous but do insurance companies wants u to loose weight during your weight lost visit for six months because I lost like 8 lbs but nothing more. and im nervous that they may deny me because I didn't loose enough. and my dr put that I exercised but on three of my weight lost visit he wasn't specific as to what exercise I did... so im very nervous because the nurse inform me that another lady was denied because the dr didn't put enough information on her papers.. can anyone give me some info on this please!!!!!!
 
So much great information. Thank you to everyone who responed. I am not the OP but I am a newbie so much appreciation!!
 
Lisa, I too have Aetna and yes it is very confusing. I had gone to a nut for almost 6 months (weekly) before I even thought of having surgery. The office's "concierge" told me to quickly get 2 more monthly visits in and that might work. I was denied initially because they said I hadn't gone to a nut for 6 mos but actually I had gone for over 9 mos. So, the surgeon did a peer to peer call with the ins co and I was approved. While all this was happening I read the info on the Aetna site and saw that 3 month program. I don't know who would have to oversee your exercise but I think that might get expensive. I started with a BMI of 40 with sleep apnea.
good luck, make sure your surgeon's office has a plan and ask them what their experience has been with AETNA.
Good luck, I hope it goes smoothly for you two.
 
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