Disclaimer: I am grateful to have insurance through my wife’s full-time employment that will partially cover my pre-surgery screenings and the surgery. I know that many people do not have this privilege. This does not change the truth that insurance policies can be complicated, subjective, and generally suck dirt.
Early on I requested a copy of my member handbook from my insurance company and began reading through the policies and calling with questions. Below I have placed a copy of my plan with notes on what pisses me off. My notes are in red…
BARIATRIC SURGERY (My insurance is HMA through PeaceHealth)
The Plan covers expenses for bariatric surgery, related doctor’s visits, and laboratory tests for individuals ages 21 through 69 (I will be thirty years old in a few weeks). Treatment must be provided by a Designated Provider according to a written treatment plan. The benefit is limited to one course of treatment. A course of treatment begins and ends as specified in the treatment plan, or sooner if the participant discontinues treatment. The Plan will cover one (1) surgical procedure under this benefit.
All of the following criteria must be met prior to the commencement of surgery:
- Body Mass Index (BMI) greater than or equal to 50 kg/m2 , or BMI of 45 kg/m2 (my BMI is currently 47.9) to 49.9 and 1 qualifying co-morbid condition, or BMI of 40 kg/m2 with 2 or more qualifying co-morbid conditions which have not responded to medical management and which are generally expected to be ameliorated, reversed, or muted by obesity surgical treatment:
This means that if I lose more than twenty pounds I will need a second qualifying condition and if I, at any time, fall below a BMI of 40 I will be disqualified.
- Qualifying Co-morbid Conditions are:
- Hypertension (I fall in the pre-hypertensive range most days)
- Dyslipidemia (I do have high cholesterol)
- Type 2 diabetes (I am at risk with a hA1C of 6.0)
- Coronary heart disease (I do not have CAD, but I am high risk related to a family history of CAD and a personal diagnosis of PCOS and metabolic syndrome.)
- Moderate obstructive sleep apnea (Unknown)
- Degenerative joint disease hips, knees, ankles, feet and lumbosacral spine (Unknown)
Despite being sick with numerous weight-related diagnosis, I have ONE qualifying co-morbidity at this time. I will need a sleep study to determine if I have sleep apnea and possibly imaging to look for DJD. These co-morbidities are not negotiable. I was even advised by an insurance rep to gain weight if I wanted surgery so bad. Why is a second co-morbidity necessary? If I am very successful on the 6 month supervised diet, I may lose weight, and therefore my BMI will drop. I do not want to be disqualified by a pound.
- Documented five-year history of morbid obesity by a healthcare provider, such as chart notes (BMI greater than or equal to specifications above).
At no time during five years can a documented weight fall bellow the above specifications.
- Evaluation by a licensed psychologist or psychiatrist documents the absence of significant psychopathology that can limit an individual’s understanding of the procedure or ability to comply with medical/surgical recommendations (e.g., active substance abuse, schizophrenia, borderline personality disorder, uncontrolled depression). (This provider must be qualified to provide pre-surgical bariatric psychological evaluations. This is actually a screening with specific criteria and not just a “You’re good! I’ll sign off on your surgery,” kind of thing.)
- Documentation of willingness to comply with preoperative and postoperative treatment plans.
- Six months documentation of participation in a designated bariatric pre-surgical program meeting all of the following criteria, in order to improve surgical outcomes, reduce the potential for surgical complications, and establish the member’s ability to comply with post-operative medical care and dietary restrictions:
- Consolation with a dietitian; and
- Reduced-calorie diet program supervised by a dietitian or nurse; and (yet if I fall below the aforementioned BMI…)
- Exercise regimen (unless contraindicated) to improve pulmonary reserve prior to surgery
- Behavior modification program
These criteria can be completed through the PeaceHealth Weight Intervention Program. (PeaceHealth likes to keep all services in-house…)
- Has not had previous bariatric surgery.
The surgery must be pre-authorized by Coordinated Health/Care prior to services being rendered. When all the above information has been accumulated, the information should be The surgery must be pre-authorized by Coordinated Health/Care prior to services being rendered. When all the above information has been accumulated, the information should be referred to Coordinated Health/Care. The plan may, in their sole discretion (subjective and frustrating), approve alternative treatment programs in the event that the above criteria is not feasible for a participant to adhere to due to extenuating medical circumstances.
The plan goes on to list facilities where I may have a surgery performed at 80% coverage, these facilities are located in another state. >_<