A couple weeks ago I called my insurance company and asked about the requirements for approval and I was told they do not have any and it is on a case by case basis. Well after some searching on Lapbandtalk.com I found a link that took me to the Anthem-Blue Cross policy page. Low and behold, they do have a policy and it was last updated on August 22, 2011. Below is the extract from the policy.
Medically Necessary:
Gastric bypass and gastric restrictive procedures with a Roux-en-Y procedure up to 150 cm, laparoscopic adjustable gastric banding (for example, the Lap-Band® System or the REALIZE™ Adjustable Gastric Band), vertical banded gastroplasty, biliopancreatic bypass with duodenal switch, and sleeve gastrectomy (open or laparoscopic) are considered medically necessary for the treatment of clinically severe obesity for selected adults (18 years and older) who meet ALL the following criteria:
- BMI of 40 or greater, or BMI of 35 or greater with an obesity-related co-morbid condition including, but not limited to:
- diabetes mellitus; or
- cardiovascular disease; or
- hypertension; or
- life threatening cardio-pulmonary problems, (e.g., severe obstructive sleep apnea, Pickwickian syndrome, obesity related cardiomyopathy); AND
- The individual must have actively participated in non-surgical methods of weight reduction; these efforts must be fully appraised by the physician requesting authorization for surgery; AND
- The physician requesting authorization for the surgery must confirm the following:
- The individual's psychiatric profile is such that the candidate is able to understand, tolerate and comply with all phases of care and is committed to long-term follow-up requirements; and
- The candidate's post-operative expectations have been addressed; and
- The individual has undergone a preoperative medical consultation and is felt to be an acceptable surgical candidate; and
- The individual has undergone a preoperative mental health assessment and is felt to be an acceptable candidate; and
- The individual has received a thorough explanation of the risks, benefits, and uncertainties of the procedure; and
- The candidate's treatment plan includes pre- and post-operative dietary evaluations and nutritional counseling; and
- The candidate's treatment plan includes counseling regarding exercise, psychological issues and the availability of supportive resources when needed.
Here are my stats:
1. I have a BMI of 38.6
2. As far as I know I do not have diabetes - but blood tests are needed to confirm which I am taking this week (My Dad and all of my relatives on his side have adult onset Diabetes)
3. I have very high cholesterol, triglycerides, low HDL - is the cardiovascular disease?
4. I don't have high blood pressure - yet
5. I think I have sleep apnea, but it has not been confirmed. I know that I snore, have a poor memory, sometimes I wake up out of breath and wake up exhausted.
6. This isn't listed but I have uncontrollable GERD. Medication and diet can't tame it.
Any thoughts?
Cheers!
Robin Wine Girl
Our bariatric surgeon was considered a "Center of Excellence" for bariatric surgery. Because of this, they gave us a survey called the "Epworth Sleepiness Scale." We scored such that it required us to have a sleep study. The sleep study showed that we, in fact, did have sleep apnea. A sleep study may be in order for you.
ReplyDeleteI would follow all the pre-approval guidelines to the best of your ability and hopefully you will be approved. Also, your bariatric surgeon's office should be able to assist you in getting approved. Even if you have to jump through several hoops. I believe the process is worth it.
Best wishes.
Like AJ, I also had to have a sleep study and did, in fact, have sleep apnea. That machine is a pain in the ass, so I am hoping after some weight loss I can rid of it.
ReplyDeleteI'm sure you won't have any problems being approved. Hopefully the process going through all the tests and everything will go smoothly. My Dad has sleep apnea and has to use a machine as well. He's lost weight from getting enough sleep...basically he stopped breathing 60x a minute (once per minute) and when he stopped snoring - it meant he wasn't breathing - scary! Hope the process goes kindly for you!
ReplyDeleteI don't think you will have a problem at all! I had a sleep study and very few co morbities but like I said previously my doctors were there to help me with those! I had slightly elevated blood sugar and was put on the lowest dose of metformin possible. The same week I had surgery I was off if it. My other doctors think it was a away to insure that my insurance company saw that if I didn't get this fixed now then diabetes WAS in my future!
ReplyDeleteThis is a stressful time and I won't deny you that at all! But I promise things will feel better once the ball is rolling a little!
I believe you should have a sleep study for sure. It sounds like you could have it. Although I did snore too and I do not have it!
ReplyDeleteThe high cholesterol is a risk to heart disease.
Just go with what everyone else said and follow your doctors orders and hopefully you will be approved!
We are here for you!
I agree with Amanda - the insurance part of it all is quite stressful. I too had a BMI under 40, but was diagnosed with sleep apnea. It was the SA and slightly elevated blood pressure (most likely due to insurance stress!) that helped me to get approval.
ReplyDeleteSounds like you're a perfect candidate. Good luck with getting approved! :)
ReplyDeleteI hope you get approved :)
ReplyDelete