So Many Questions...

[Oneheadlight]

I'm gathering information to submit to my insurance company (PEIA). My BMI is 54 and I can provide documentation of it being at least 50 for the past 5 years.

I'm sure to be denied because, although I have been meeting with my PCP (for ten of the required TWELVE appointments) I have not lost 10% of my body weight. Also, my insurance company denies everyone.

I called to schedule a consultation with the surgeon and was very discouraged to hear that they basically didn't want to meet with me because I will be denied. They also said my insurance won't cover the consult.

I assured them that I would pay for the consult out-of-pocket because I need the denial in order to proceed with an appeal. I think once they have all my information, I will have an appointment.

I have to meet with a nutritionist which is covered by my insurance. I also have to have a psychiatric evaluation which is required for the insurance but not covered at all.

I have so many questions I don't really know where to start. Can they require something they won't cover? Do I go ahead with the psych evaluation? If it ends up being out of the time framewill I have to do it again and pay for it twice?

I have more questions, this is just the tip of the iceberg

 

[DSRIGGS]

Two points:

Your surgeons office needs to be submitting for approval not you, and I don't know that i have heard of any requirement to lose weight through a diet to gain approval. The only requirement that I am aware of by some plans is that you actively participate in a physician supervised diet per the term your insurance company mandates. I had to have psyche evil and do the diet for 6 months. I lost a few pounds but honestly didnt try to as both my PCP and I found the diet to be ludicrous.

Who is your surgeon and are you seeking a DS? They do this stuff all the time and should be able to make this happen, so call them tomorrow and tell them you need their help with this.

 

[southernlady]

PEIA???? What state? Is it an employer provided insurance or one from the ACA? Is it a Medicare or Medicaid program?

As far as the requirement to lose 10% of your weight, that really depends on your policy. You need to have a copy of your EOC (Evidence of Coverage) which is about 80-100 pages long (really a book) that details all aspects of YOUR personal coverage under their plan.

Btw, welcome @Oneheadlight

 

[Oneheadlight]

Thanks for the replies. I misspoke when I said I was submitting that, I'm just trying to gather my info right now.

I'm hoping that Dr. Shin with CAMC will be my surgeon. I went to an informational seminar over a year ago at his practice and was very impressed. I'm leaning toward going with the sleeve but I'm not 100% sure.

I have PEIA in West Virginia and it is an employer provided program. I have a Summary Plan Description that doesn't say much about Bariatric surgery other than it is covered and the co-pays. There is an additional 8 page document that outlines all the requirements. Should I be looking for something else?

I just tried to provide a link to both of these things but I don't have enough posts to do that yet.





This is just the first two pages. I'm sorry it's so huge, when I put it as a tuumbnail you can't read it.

 

[Clematis]

OMG they REALLY don't want people to have WLS, do they? Their requirements are more stringent than any I have seen.

I have no advice for you, just sympathizing.

Oh, and welcome.

 

[Oneheadlight]

This isn't even the whole thing. Yes, they really don't want people to be successful.

I don't know one person with this coverage who has had any type of Bariatric surgery. The people I know are either insured through their husband's insurance, or they went to Mexico.

When I attended the seminar, they did have one person with PEIA with a surgery date. I guess that means they don't deny every single person.

I am on my husband's insurance, but he has PEIA also, so that doesn't help.

Thanks for the support

 

[DianaCox]

Oops, I just noticed I wrote this yesterday and didn't post it. I have additional comments based on your later post:

Who has the 10% weight loss requirement? Your surgeon or the insurance company? Is that West Virginia public employees HMO?

Those requirements are medically unsupported. Find out what is the GRIEVANCE procedure for your plan, so you can file a grievance, asking them to waive this unconscionable requirement.

http://asmbs.org/resources/preoperative-supervised-weight-loss-requirements
http://asmbs.org/resource-categories/preop-weight-loss

You should be able to have the consult now - but you need to do things in order. Request preauthorization from your insurance for the consult, saying your surgeon won't let you make the appointment because of the requirement. If they REFUSE, then you have a denial, and you can file a grievance.

Once they deny (assuming they do), you can self-pay for the consult (assuming you trust this surgeon's office when they won't stand up for you against the insurance company), and then simultaneously APPEAL (it is a different procedure than the grievance).

The other thing you need to do is get a copy of your Evidence of Coverage document (the contract - should be 80-100 pages long), as well as their bariatric policy. And you need to find out whether your plan is self-funded or fully funded - I'm guessing it's self-funded, to avoid the ACA requirements - find out if the plan is grandfathered too.​

Your plan requirements are OUTRAGEOUS - almost NOBODY can meet those requirements. You need to file a grievance, demanding that they WAIVE these medically unsupportable requirements. You must immediately find out what the grievance procedure is. I'm not sure who you can ask, because I don't have the plan documents.

Alternatively, you can ask your surgeon to submit for you, EVEN if they know you are going to be denied, because getting the denial will trigger your appeal rights to get this unreasonable and medically unsupportable set of ridiculous requirements waived by an outside review agency. But without seeing your plan, I have no idea what your appeal rights are, and to whom the external review would go (or if you're even entitled to one).

To be honest, I would change jobs if at all possible - this is a RIDICULOUS restriction on your medical care.

 

[BebeZed]

Whoa... talk about restrictive requirements. I wish you the best of luck!
And welcome!

 

[Oneheadlight]

The insurance company requires the 10% loss. It used to be 5% but they increased it. PEIA is a PPO for public employees in West Virginia.


I will need to call and ask about the grievance procedure. Where would I look in the plan document to find that? I can find info on the appeal procedure but not the grievance.

So far I trust the surgeon's office. I think they will work with me on this.

Is the Evidence of Coverage document the same as the Summary Plan Description?

No clue if it is self-funded or fully-funded, but I will ask. I will also ask if it is grandfathered. I have the Bariatric policy.

Although I would like to change jobs, I don't think that is in my future. I'm going to have to deal with this.

Diana, thank you so much for your suggestions. It feels great to have a starting point

I'm glad people around here seem to think this is as outrageous as I do

Here is the information on my appeal procedure. Sorry for the size of this. Since I can't post links yet, I don't know a better way.

 

[DianaCox]

Call your state department of insurance and ask them how to file a grievance. A grievance is against a POLICY - it is procedural. An appeal is based on a mistake alleged in applying the policy in a particular medical setting is substantive - it alleges that you should have been covered but were denied.

Their policy is ridiculous. It is designed to be, in fact, a way to deny the VAST majority of people who need medical care for their disease of morbid obesity. However, because your insurance plan is likely self-funded, it may not be required to cover bariatric surgery at all - and in fact, in essence, it does not. Finding out whether your plan has to meet the terms of the ACA is an important step, but even then, at the moment, the ACA does not require that ACA plans cover bariatric surgery.

You might want to look at this, and possibly even give the TOS a call: http://asmbs.org/articles/american-...f-obesity-treatment-under-affordable-care-act

 

[Oneheadlight]

Thanks for clearing that up. I really appreciate it.