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Wednesday, January 25, 2006

Insurance Obstacle Course

I've been trying to figure out exactly what my requirements are for BCBS-TX to cover my WLS. I definitely qualify on BMI, and my doctors agree it would be fine for me, however I'm not sure if my 4+ years of Weight Watchers books will count as a "medically supervised diet."

I called Dr. Naaman's office and spoke to Bernie. I asked her if she thought BCBS would take my 4+ years of Weight Watchers. She said it's fairly subjective to the reviewer on your case. Great! She said the best thing to do would be to call them and ask them what the requirements are.

So, I did.

Mary from BCBS was just as sweet as can be too; not at all what I was expecting with all the horror stories I've heard. I could tell she was really trying to find the information for me, but was having no luck. She said, if it were up to her 4+ years committed to anything should get me covered, but the case reviewers don't always see it that way.

I found some documentation on the provider website that said if a pre-certification was requested, BCBS could ask for a 12 month, medically supervised, diet. Then, later, to corroborate that, Paul on Obesity Help said that BCBS does not waiver on their pre-cert requirements for wls, citing the same document I had found. Great... Not!

I'm trying not to stress about it though. There is such a long haul ahead of me, and everyone's insurance experience seems to be different. The worst case scenario is that I have to wait a year, to meet the requirement of a 12 month medically supervised diet.

I've decided to write a letter to BCBS on my own behalf. In addition to that I'll have the letters of 2 physicians, as wells as two obesity survivors who know my dedication towards living a healthy lifestyle. I knew them both when I was on Weight Watchers.

I wasted no time and found a Medical Weight Management program at Methodist Hospital. Hell! If this works they way they say it will, I might not need surgery. Seriously! It sounds like you follow the diet as you would after bariatric surgery. They start you out on liquids and then transition you to food. Later, you move on to maintenance. They say 2 to 5 lbs. a week. You are medically monitored weekly, so it would qualify for pre-cert.

Of course though, insurance does not cover it. :c(

Why is it they'll cover $25K surgery, but won't cover a weight loss support program at a fraction of the cost?

Regardless though, I will look into it anyway. I mean, if I have to meet the requirement, I may as well do something that may bring me benefit.

If I have to wait a year, and I lose weight in that time, I'm just making things easier on my body for the surgery. That's how I have to look at it, otherwise I'll go nuts!

Here's to meeting my first challenge.

1 comments:

MrsAmyB said...

Hey - it's me - I signed up here just to stalk you - J/K - I thought it was a great ideato have my own "private" space for WLS journaling. Plus I can access from work - so I am exploring - I hope you don't feel like I am intruding.
It's amazing how things have changed with insurance companies over the past few years. When Tom had surgery he had BCBS and they approved him in a matter of days with very little requirements - and now I hear it is virtually impossible to get approved without the 12 month supervision. I had BCBS when I first thought of the surgery - but I had this very narrow window to go through to get on Tom's Aetna plan - and I checked their requirements and it is only a three month program - so even though we are paying more for his insurance - hopefully it means I will get covered sooner.
Stay strong and stay committed! I started to contemplate self pay - The WISH center offeres financing - many bariatric places do not because of the new harsher insurance requirements. It's a hefty bill but no more then a new car and well worth it for the years it will add on to your life and the improvement of quality of life.

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