United Health Care/NJ Family Care revision to DS surgery questions

[OrganicLife]

I have United Health Care/NJ Family Care as my health insurance company.

I spoke to my primary doctor, and she gave me name of a doctor in Newark, that isn't on any of the lists as a revision doctor or a DS doctor. I won't be contacting that Dr. I know I will most likely go with Dr. Greenbaum. I saw that he does accept my insurance.

My first WLS was self pay, because the insurance I had years ago, did not cover WLS. So, I paid out of pocket for the vsg.

Being that this next surgery, whenever it happens, it will be a revision and to complete the DS. I want to call the insurance company, but I'm not sure if I want to reveal too much to them, incase they deny it. I know they cover revisions if there is a problem with the original surgery, or weight did not come off. Should I just have the Doctor's office handle the paperwork part for the surgery with the insurance? In the insurance eyes, it would be the first time I am using their insurance for WLS. Does it matter that I've already had a WLS and it was self pay and this next one is a revision with insurance? I just don't want to get denied. I hope I made sense

 

[DianaCox]

Let Greenbaum submit. But you have a right to know what YOUR policy says. Go to your HR or whomever holds the policy and get a copy of your Evidence of Coverage document (which is your full contract, and should be about 100 pages long - NOT just the summary, and NOT just your insurer's general policy).

"In the insurance eyes, it would be the first time I am using their insurance for WLS. Does it matter that I've already had a WLS and it was self pay and this next one is a revision with insurance?" No it doesn't matter - if your insurance has a "one-bariatric-surgery-per-lifetime" exclusion, it doesn't matter who paid for the first procedure - they will deny the second one. Which STILL doesn't mean you can't appeal. And your surgeon will have to disclose in his request for preauthoriziation that it is a revision/conversion. The best he could say is that it is the second step of a proper DS, which you should have had in the first case, but which was staged as a two step DS.

 

[OrganicLife]

Thank you Diana. I will get the full contract. I will be making the appointment with Dr. Greenbaum.