Ok, you have found out that your insurance company requires pre-surgical weight loss program and other information prior to submitting a request for authorization.
What do you need to do?
In most cases, just a letter of necessity will not be sufficient. Find out if your company posts their criteria on their website. If not, ask for it in writing. Make certain you are following all of the steps and not just one or two.
If you are asked for a 2 year history...get copies of your actual chart notes from your primary or specialist that shows your weight at each visit. If you are asked to go through a physician directed weight loss program prior to surgery, be sure to see that doc at least once a month and obtain copies of those chart notes as well. Make certain they are writing your weight at each visit.
If they ask for letters of necessity, please ask the doctor that is writing them to not just say "I believe this surgery would be appropriate for XXX" Ask the doc to go into detail why their professional opinion is that it would be good for you.
If you are turned down, review the package of information that was submitted to make certain some key piece of information was not sent. Then look at details to see if you followed all of the steps. If you have a
BMI of 33 and your company states they will only consider if the BMI is 35 or higher, even if you do all of the other steps, you will be turned down for approval. If you only provided chart notes for three months of pre-surgical weight loss and they ask for 6, you will be turned down. If you did do the 6 months but only saw the doc three times during that 6 month period, you may be turned down.
These are just some general suggestions but in my experience, if you meet the basic BMI requirements and you provide all of the documentation, you will be approved. If anything is missing, you most likely will not be approved until that information is provided.
Why is all this documentation needed? Unlike an auto insurance company, who sends an adjuster out to actually look at the damage to your vehical, medical insurance medical directors only have a piece of paper to look at to make a coverage determination. The more information you provide will give them a better "picture" of your situation....and the better outcome for a review.
Robin
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Body Mass Index BMI
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A statistical method of figuring out the degree of excess or insufficient weight based on one's height & weight. Though the controversial BMI does not actually measure the percentage of body fat, it is a useful tool to estimate a healthy body weight based on how tall a person is. |
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