Insurance Hoops - Surviving the Insanity!

Congratulations! You are ready to have surgery. You have decided on a surgery type, you have picked your surgeon, now comes the insurance hoops to jump though for those going through insurance.

Some insurance companies offer limited surgery types. Some will only pay for bands and bypass. Some will only pay for sleeves or DS if your BMI is over 50. What if you want a sleeve and your insurance will only pay for bands and bypass?

APPEAL APPEAL APPEAL!

It isn't a sure bet that your insurance will approve an appeal but what do you have to lose?

Now, every insurance company I have looked into and researched require a BMI of 40 or greater to be approved for weight loss surgery. Most will accept your 35 BMI *if* you have very specific comorbidities. Typically they want to see active high blood pressure, diabetes, sleep apnea, and/or a history of heart disease. Although we have a poor quality of life with back pain, joint damage, an inability to breathe well, borderline high blood pressure, pre diabetes, asthma... those just don't count. They are typically very specific which cormorbidities they require for a BMI of 35 - 39.9.

What if you have high blood pressure but it is controlled with diet alone? No, it does not usually count.

What if you are pre-diabetic? No, it does not usually count.

What if you have a family history of strokes, diabetes, high blood pressure, and/or sleep apnea? No, that does not count.

You have to be actively treated for these things by a doctor with medications and such before the insurance company will consider them comorbidities. Remember, insurance companies are not strong in common sense. You have to think like them to understand them. Yes, they would prefer to pay for your heart attacks, dialysis, and other related expenses than to pay for your weight loss surgery if it is something they do not cover. They act like a computer, computers do not think, they just spit out information. Computers follow rules, they have no common sense. They don't look at the best value for a dollar spent. Information in, information out. That is exactly what an insurance company does. Some people write long letters to the insurance company begging and pleading for coverage when they do not qualify for some reason. It does not matter. The insurance company (think computer) does not care about you as a human being that is sick and miserable. They care if your blood pressure is high enough and if you are obese enough. If the numbers add up they will pay for your surgery. I know it is not right and it is not ethical, but this is how it works so you will do better for yourself to accept this is how it works and approach it from the right angle. No, life is not fair and no, it is not right but they call the shots and they usually get to have their own way.

What if you want DS but your insurance pays for bypass or bands? Many think if they need NSAIDs (Aspirin, Naprosyn, Motrin, etc.) they can appeal based on this since you cannot take NSAIDs with bypass. They will likely deny you because they do offer bands and you can take NSAIDs with bands. (History: It used to be that doctors thought NSAIDs could not be taken by band patients due to causing erosion, that has since been shown to be inaccurate, NSAIDs do not cause erosion in banded people.)

I recall one person that was just sure he could get a non-covered sleeve on appeal based on the fact that he is deficient in Vitamin D. That is a no-go as well. Most of the US population is low on Vitamin D. Supplements will bring it up and therefore if they cover bands and bypass, they are good to go. Keeping in mind that many times the number of times you may appeal are limited, don't waste your appeals on what you know isn't going to work.

What if you weigh 900# and you have no benefits for WLS? You are out of luck. Yes, once again the insurance companies would rather pay the hundreds of thousands of dollars to treat what weight loss surgery would fix.

Many (most?) insurance companies will not pay for sleeves. They consider the procedure to be investigational. The ASMBS disagrees and they no longer consider the procedure investigational. Let's realize one issue here, the sleeve is not new! The weight loss stats are new, not the surgery itself. With some insurance companies - some of the time - you can appeal and get a sleeve by proving it is not investigational. Once Medicare starts paying for sleeves then you will see more insurance companies beginning to follow suit as well.

What if they require a medically supervised diet for 3-6 months? How does that work?

It really depends on the wording of the insurance company. If they want a "medically supervised" diet they want you going to your doctor and/or nutritionist monthly. They want documentation of effort on your part to try and change eating behaviors, exercise, and sometimes psych care to treat a "medical" problem of obesity. (I know, that doesn't usually make sense either, it's like going to your psych for your diabetes!) They want to make sure that every 25-30 days you have been to your appointments. Not 32 days but 30 days. They want your medical provider to document your weight, the change in weight from the previous month, and written data showing they worked with you on diet and exercise.

If they do not specify "Medically Supervised" then they probably mean something like Weight Watchers, Jenny Craig, some sort of proof that you tried and participated for 6 months. Ask your insurance company and if your policy is not clear make them put it in writing.

What if your insurance company wants proof that you have been a specific BMI or greater for the last five years? If you are anything like most, most of us have dodged doctor's scales for years. It might not be in your medical records what your weight was so be creative! What does your weight say on your drivers license? Okay, if you are like most you are at or near your heaviest today but you still show 150# on your license. But, if you told the truth on your license and it shows your BMI is what is required, that can be put toward proof for that year.

Photographs! Some photos are dated by an outside source (other than your digital camera) such as Walgreen's Photo Dept. If it is obvious from dated photos that you met the BMI requirements, that can often times be used as well.

Emergency Room visits - think back to anytime you might have needed to go to the hospital for sutures or a broken bone. They usually insist on weighing you. Those records can be used to prove BMI requirements.

Be creative and find whatever is necessary to prove your BMI if you do not have proof at your MD office.

What if you lose weight on the supervised diet and fall below the required BMI? You are safe. If you met all the BMI requirements in the beginning of the insurance approval process it is okay if you fall below on the required diet. Can you imagine the lawsuits otherwise? They require you to lose weight to prove your mind is made up and this is what you want then they deny you because you did exactly as you were instructed. Lose weight on your pre op diet, it's safer for you at the time of surgery.

Usually you have to meet other requirements that are equally silly to have insurance pay for your weight loss surgery. They want you to go to a bariatric surgeon for an eval. They may want you to see a psychologist to see if you are mentally prepared for surgery, this is just an eval and not an on-going therapy process. If they suggest you need therapy before surgery ask if you are required to go to them for your therapy before they will approve you. It *might* be a way to force you to continue going back for sessions just to pad their pockets. This does not happen often but it does happen. If you want you can always get a 2nd opinion.

They want you to do a sleep study to see if you have Sleep Apnea and this is something weight loss is likely to fix anyway. They want you to see a nutritionist for an eval prior to surgery. This one annoys me as most nutritionists do not have a huge base of knowledge on weight loss surgery. They will tell people to eat far more calories than possible after surgery. All surgery types limit quantity of food. Just how are you supposed to eat 1800 calories a day with a stomach the size of a ping pong ball? Top that off with their instructions NOT to drink your calories and you see my point. They have more training in people that have specific medical conditions such as wheat allergies, need a gluten free diet, etc. Sometimes they may not understand our issues. If you can go to a nutritionist that is also a WLS patient, all the better.

Many nutritionists will give you a diet for bypass but if you have other surgery types, it doesn't work. For example, DS patients NEED and REQUIRE a very high fat diet but their instructions are likely to stay on a low fat diet. DS folks malabsorb 80% of their fat intake and to keep losing weight they absolutely must eat a high fat diet. I can give you many examples but my advice to you is to ask for a combination of what you should eat. What percentage of your daily food should be carbs, protein, and fat? Listen to your doctor and not your NUT (nutritionist) about caloric requirements. Ask how many grams of protein you should be consuming daily. But again, ask your doctor about caloric requirements.

Dealing with insurance companies is no easy task. Some insurance companies are easier to deal with than others. If all else fails, have your surgeon do a peer to peer review with them. That means your surgeons sets an appointment with the doctor at your insurance company and he explains why you must have "X" surgery type instead of what they say they will pay for.

**NOTE: Regarding peer to peer reviews, this is a LAST option. Do not use this for your 1st or 2nd appeal or you *will* be denied. Insurance companies do not want their doctor tied up doing what the appeals department should be doing. So use it as a last and final option.

If that fails you have one more option. Seek the advice of an attorney. There is one attorney that does nothing but this type of work. It seems somewhat affordable and they appear to have a good track record. I prefer not to advertise specific businesses that I have no personal experience with but you can go to www.obesityhelp.com and post most anywhere asking for this man's name and you will get your answer. I would not suggest contacting your family attorney as he does not likely specialize in this and he doesn't know the ins and outs of insurance companies and weight loss surgery. It may end up being far more expensive going through your own attorney just because he may need to take more steps and charge you for each step until he finds the correct appeal paperwork. But clearly, this is your choice.