Guest guest Posted October 3, 2001 Report Share Posted October 3, 2001 The only thing that might be difficult is there definition of MO. Otherwise it is definately covered. They say MO is 200% of ideal weight. I don't know according to the met charts what your ideal weight would be, but since you are 320 by their definition you ideal would have to be only 160. However, I would be you can argue that an over 40 bmi is MO not 200%. Dawn--South Suburban Chicago area Dr. Hess, Bowling Green, OH BPD/DS 4/27/00 www.duodenalswitch.com 267 to 165 5' 4 " size 22 to size 10 have made size goal no more high blood pressure, sore feet, or dieting Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 3, 2001 Report Share Posted October 3, 2001 Steve, The requirement that you be 2x ideal body weight means your BMI must be >45. For your height a BMI of 45 is equivalant to 327 lbs, so you are right on the boarder. Wear some heavy clothes when you weight in! Most other companies and the NIH consider BMI>40 to be the criteria. For more discussion of insurance issues please join as at: DS-Insurance_Authorization_Problems For a discussion on the California Surgeons please go to: http://groups.yahoo.com/group/duodenalswitch/files/ Then click on " Hull's Folder " There you will see a number of files including: The California DS Surgeons.doc This file contains information on that will be of interest to you. Hull > I have an initial consult 11/1 with Dr. Rabkin. I am investigation my > insurance coverage and this is the exclusion for MO. > > I am 40, 5'11.5'', and ~320. > I have sever sleep apnea and pitted edima (also minor CHF) > What do you think my chances are > > ******** Directly from Ins. Coverage ************* > exclusions: > > Charges for diet or weight reduction except for the medically > necessary treatment of morbid obesity (a body weight that is 100% > over the weight given in standard tables); endogenous obesity (caused > within the body) including but not limited to metabolic factors such > as hyperinsular, hyperinterrenal, hypogonad, hypothyroidism, > hypercholesterolemia and obesity due to hypothalamic lesions; or > exogenous obesity (caused by overeating) if: a diagnosis or morbid > obesity is given and a separate medical condition is present which is > aggravated by obesity (e.g. high blood pressure, chronic back > conditions, varicose veins, etc.) For surgical treatment of morbid > obesity, you or your covered family member must be: > a) twice your ideal weight; > demonstrate inability to control weight through diet over a > minimum of a five-year period documented by a physician's medical > records, and must suffer from a documented separate condition which > is aggravated by obesity (e.g. severe diabetes mellitus, > hypertension, alveolar hyperventilation, a chronic back condition, > varicose veins, etc.). This must be documented by objective evidence > provided by the treating physician; and > c) you or your family member must be psychiatrically stable as > documented by a recent psychiatric evaluation. > ************************************************************ > > I am also looking at other surgeons (i.e. Dr. Jossart, Dr. K, Dr, > Anthone) in the CA area. > > Any help would be appreciated. > Steve Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 28, 2005 Report Share Posted January 28, 2005 Hi Steph, I also had MAJOR issues with my insurance company. All I can tell you is something you've probably already been told: 1. Get a notebook... Write EVERYTHING down. NAMES of people you've spoken with, dates, times, what they said and get reference #'s for every call. 2- If you feel you finally get through and hear something that sounds good, have them write it down and FAX it to you... they are famous for saying " I have no record of that " 3- I was told 8 months after starting my battle and speaking to people in every department, in 4 different states and across all levels of beaurocracy that he reason it was not handled properly was I " never asked for a supervisor " . I was stunned, not only because I HAD asked for a supervisor but because I had also vocalized every version of " if you can't help me, please connect me with someone who can " in EVERY SINGLE phone call. Apparently " supervisor " was the buzzword that did not show up on the record and would have solved all my problems... I'm sure. Good Luck! Eventually I did get my surgery covered. $16,000.00 worth of coverage... I had to report the insurance company to the Board of Health in order for them to take me seriously. I would have been afraid to do that it I did not have good records. Cheers! Tova > > My surgeon's office had contacted my insurance company to get > preauthorization for my lower jaw advancement in 2003, got approval > for inpatient surgery and 2 days in the hospital in July 2003. So I > went ahead and got braces to get ready for the surgery. > > My company's group number changed, so we needed to resubmit the claim, > which was just denied. When I talked to my insurance company (Cigna) > yesterday, they explained that the original form that my surgeon > submitted was only for the hospital, not for the surgery. The only > oral surgery coverage I have is to have wisdom teeth removed. > > So - is there another way to submit the claim? Does this kind of > surgery fall under some other sort of classification, other than oral > surgery? B/c what if something else was wrong with something in my > mouth, like cancer? There must be something, since people need oral > surgery for things other than just wisdom teeth!! > > Has anyone else had experience with this? Is your surgery covered > under something other than your oral surgery benefits? Any idea of how > much the surgeon fees would be? It looks like they'll pay for the OR, > meds, and hospital stay still. > > Thanks! > > Steph > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 29, 2005 Report Share Posted March 29, 2005 Hello, I was just wondering how long it took for insurance to pre- approve the surgery. I had BC/BS and had basically been approved but my company switched us to Aetna this year. My OS wrote to get the preapproval and they asked for all kinds of records. I went in for them to take everything the insurance asked for. That was a couple months ago and I still haven't heard back yet. I was just wondering if that is typical to wait that long. Also, if anyone has dealt with Aetna, have you had any problems getting them to approve? I'm hoping not to be waiting till last minute for an approval. Thanks for any info you can offer. Quote Link to comment Share on other sites More sharing options...
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