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Old 01-17-2008, 09:25 PM   #1
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smurfswifey HB User
gastric bypass and health insurance?????

I have a question...I was on here a month or so ago asking if anyone knew if united health care would cover gastric bypass surgery. I called my insurance company like it was suggested. I was told by the lady on the phone that they do not cover anyhting to do with weight loss unless I was morbidly obese. I am- I weigh 360 and am 5'3. The only thing she could manage to tell me was get papers together from my doctor and send them in. I was hoping she could tell me if there were certain things I have to do to be considered or anything. She was just so vague! I have been overweight my whole life. I have tried weight watchers, the biggest loser, joined gyms, pretty much any diet you can think of, I've done it. I always lose a little, but never enough. I am just soooo frustrated! If I can't get a straight answer from the insurance company, I have no idea what to do. I have not been to the doctor in 2 years, (because of no insurance). My feet are starting to hurt even just to walk, I think I may be diabetic, and my blood pressure is up. I am scared the insurance company is going to say because I haven't been to the doctor until just recently that I haven't given it enough time. I started going to the doctor at age 12 for weight, but like I said it hasn't been constant that I have been able to go. I go for a consultation next week on the 24th, so maybe they can give me some insight into what I should do. I am fully aware that I am in charge of my life nad that I did this to myself, but it is a cycle that I just can't break.....I need help so bad, and I feel this is my last resort. I hope the insurance company see's it that way also. If anyone has any idea's or maybe someone that has had the surgery and would like to share some if this info I would really appreciate hearing from you.

 
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Old 01-18-2008, 12:17 AM   #2
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jbzcar HB User
Thumbs up Re: gastric bypass and health insurance?????

What a wonderful coincidence that on the day I register here I find this thread.

Wondering why? Well, it's because I have FIRST HAND experience concerning United Health Care and gastric bypass surgery. I am actually 6 months out of surgery myself and have lost ~133 lbs.

Here are UHC's basic requirements to cover GB surgery:

1. DETAILED letter from both GP and bariatric surgeon explaining why the surgery is medically necessary.
2. At least a 5-year documented (like from your chart when they weigh you every time you go to the doctor) history of obesity.
3. There *may* have been a BMI requirement, but based on what you said in your post, your BMI of ~64 would meet it easily.
4. I am pretty sure that is all, but I may have left something out, lol.

It really is not all that difficult of a process to complete, so I will line out the basic steps for you. Your bariatric surgeon (PLEASE do research before choosing one!) will know the nitty-gritty ins and outs better, but this is basically how it worked, at least in my case:

1. My GP told me that I appeared to be a perfect candidate for the surgery. I was 23 at the time with a heigth of 5'8.5" and I topped out at 318 lbs. He referred me to Dr. Robert Davis here in Houston. One of the best bariatric surgeons around. You might have seen his show Big Medicine on TLC.
2. Because UHC requires that letter I mentioned above, your GP should have you undergo a battery of tests to determine if any comorbid conditions exist. For example, I was required to do a nuclear stress test, a sleep study, various ultrasounds of my neck veins/arteries and heart, and, most unpleasently, get an endoscopy/colonoscopy. The reason behind this is the more problems you have, the easier it is to convince the insurance company. You should also meet with a psychologist and a nutrionist who will add their own notes/observations to the packet. I suffered from several comorbid conditions - mainly high blood pressure (was on medication every day), sleep apnea, and severe insomnia. I also had some records of previous failed weight loss attempts.
3. Once all the results are compiled, your GP should forward them along with his letter to your BS, who will then add his own letter and send the whole thing off to UHC.
4. Then the waiting game starts. Luckily everything for mine came back approved within about 2 weeks.
5. After the approval comes in, all that is really left is to get put on your surgeon's schedule.

My surgeon required a liquid diet for the 14 days prior to my surgery. This is to shrink the liver and allow for him to work much easier inside my body. Many surgeons have different ideas/plans for the pre-surgery diet, but most only differ in length - usually anywhere from 3 days to 2 weeks.

So, it may take a little time to get everything together, but after that you shouldn't have any problems.

Also, IIRC, UHC will only pay for 80% of the surgery, so you will have to come out of pocket a few thousand more than likely. Don't let that deter you, what you want to do is a great goal to strive for!

Please let me know if you have any questions and I will do my best to answer them.

 
Old 01-18-2008, 05:58 AM   #3
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smurfswifey HB User
Re: gastric bypass and health insurance?????

Congatulations on your weight loss! That is awesome! I'm really glad that you wrote, I was starting to feel like I would never get any answers.

I have another question for you....You had said in your reply that you have had documented attempts that failed?? I haven't really had any documented attempts with the doctor, but I have tried several things on my own that didn't really work. My weight has climbed from 260 after having my daughter 9 years ago to 360 now though Right after I had my daughter I did go to the doctor for a couple months for weight loss, but due to health insurance restrictions the doctor had to document it in different ways(I believe he just called it a physical the first time and checkup with things from the physical later??) My insurance at that time wouldn't cover anything weight related either. I guess my question is- Do you think there will be a problem because I haven't been able to go to the doctor on a regular schedule, as far as proving that I have tried ??? Until recently I was without insurance and just couldn't afford to go all the time. Also, how long did it take to get all the required testing done? I probably sound like a crazy person,lol..but I just need to get this done so bad, I am worried something will go wrong and I won't get approved.

 
Old 01-18-2008, 10:36 AM   #4
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jbzcar HB User
Re: gastric bypass and health insurance?????

Quote:
Originally Posted by smurfswifey View Post
Congatulations on your weight loss! That is awesome! I'm really glad that you wrote, I was starting to feel like I would never get any answers.

I have another question for you....You had said in your reply that you have had documented attempts that failed?? I haven't really had any documented attempts with the doctor, but I have tried several things on my own that didn't really work. My weight has climbed from 260 after having my daughter 9 years ago to 360 now though Right after I had my daughter I did go to the doctor for a couple months for weight loss, but due to health insurance restrictions the doctor had to document it in different ways(I believe he just called it a physical the first time and checkup with things from the physical later??) My insurance at that time wouldn't cover anything weight related either. I guess my question is- Do you think there will be a problem because I haven't been able to go to the doctor on a regular schedule, as far as proving that I have tried ??? Until recently I was without insurance and just couldn't afford to go all the time. Also, how long did it take to get all the required testing done? I probably sound like a crazy person,lol..but I just need to get this done so bad, I am worried something will go wrong and I won't get approved.
What I really meant was I explained to my GP my previous attempts and he "worded and worked them" into his letter.

And no, there was about a 3 year gap in my weight history when I didn't go to the doctor either, but as long as I could provide at least 5 years of charts showing I was obese, it counted just fine.

 
Old 01-21-2008, 04:26 PM   #5
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smurfswifey HB User
Re: gastric bypass and health insurance?????

Just wanted to update. I talked to the insurance company today and they had me transfered to snother department that deals with all of this. The lady I talked to this time told me the same thing you told me. I am sooo excited, it should be pretty easy to get all that together. Thanks for the replies!

 
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