I called Capital BlueCross to ask if they received the pre-auth request from my surgeon’s office. The woman I spoke with said that so far nothing is showing up in the system, but once they do have it, approval usually takes 72 hours or less. She also assured me that so long as the criteria is met:

• six month nutrition/weight loss program
• program is done at a Center of Excellence
• I have a BMI of 40+, or a BMI of 35-40 with co-morbidities

… I’ll be approved with no problems.

*This is me doing my pre-insurance approval tentative happy dance*

Anyway, I just printed out my food log from the past month, as it will soon be time for me to hit the road if I plan on making it to my last group session!

The surgical weight loss center called this morning to confirm my appointments for this week:

Today: the last of the three group sessions. I originally was scheduled to attend the last group session on Thursday, but that session is for band patients. Since I am having gastric bypass, I’ll be attending the gastric bypass group session, which is today. It’s at 2:30, and will probably last at least an hour.

Thursday, November 5th at 8:30am: second and last appointment with my surgeon.

Thursday, November 5th at 11:30am: appointment with pre-admissions and anesthesiologist

The woman I spoke with also told me that they submitted the paperwork to my insurance company last week. Once the pre-auth comes back, I’m good to go. To be honest, I’m waiting on that to come through before I go absolutely crazy about having weight loss surgery. In my mind, until the insurance company gives its seal of approval, I’m not 100%, definitely, for sure, absolutely without a doubt having surgery, you know?

Right now my biggest fear is not getting insurance approval for the surgery. Once my surgeon confirms that the insurance will cover the surgery, I’ll be able to breathe a lot easier. When I first started contemplating surgical weight loss two years ago, one of the first things I did is call my health insurance company (Capital BlueCross) and ask if they covered it. They looked up my specific coverage plan (which is provided through my husband’s employer; we pay nearly $500 a month to cover the two of us) and confirmed that yes, surgical weight loss would be covered, provided that I went to a participating provider and met the eligibility requirements. I’d also have to pay a deductible (based upon the entire year, not specific appointments and procedures) and 10% of surgery costs (which I’m guessing will be somewhere in the range of $2000?).

But that was two years ago, and a lot has changed between then and now. Namely, the economy. Also? My husband’s company is cheap, and after reading about many people finding out that their weight loss surgery would not be covered because their employer didn’t pay for it for the company’s health care package, I wondered if that might unfortunately be the case for me. Fortunately, it’s not. Next to me is a thick booklet titled “Certificate of Coverage”, and it’s for 2009. On page 46, under the list of exclusions, is the following (the emphasis is mine:

For treatment of obesity and/or morbid obesity, except for surgical treatment of morbid obesity

Well, that’s a sigh of relief. My plan still covers weight loss surgery, and backs up what a rep told me over the phone and in writing two years ago.

I have chosen a center of excellence for my surgery, which means that they are preferred/recommended/almost always covered by Capital BlueCross. I also more than qualify for surgery, since morbid obesity is a BMI of 40 or greater, and mine is around 47.

Logically I know that my insurance company will approve it. I have done everything as directed by the center of excellence, I have the backing of a surgeon and several nutritionists and dietitians, and they themselves said that Capital BlueCross and other BlueCross subsidiaries rarely give them any trouble. But still, until the approval is official, I am going to be edge, and holding back from fully “preparing” for surgery, since there’s still the uncertainty.

I emailed my insurance provider around 4am, and they replied this afternoon (I <3 them for their quick response!):

The following gastric restrictive procedures: gastric bypass using a
short Roux-en-Y anastomosis (less than 150 cm), vertical banded
gastroplasty, gastric stapling, or adjustable lap banded gastroplasty
may be considered medically necessary and appropriate for treatment of
morbid obesity.

Your policy does provide benefits for eligible surgical expenses when
determined to be medically necessary. [Blah blah blah, insurance talk about deductibles and such.]

Your policy requires preauthorization for these types of surgical
procedures. This means that your provider will need to contact our
Clinical Management department prior to the surgery and your inpatient
admission. Clinical Management will determine whether the service is
medically necessary.

I wanted to cry in relief when I read that letter. It does echo most of what the woman I spoke to on the phone with last fall said to me. It’s good to see it reaffirmed in writing!

And I definitely meet the “medically necessary” criteria, particularly in regards to having a BMI of over 40 (48-49) AND being 100 lbs. or more overweight (my ideal weight is 121 lbs. – 155 lbs. and I’m currently 309 lbs. You do the math!).

Excuse me while I float off on my cloud…

309.2 lbs. I’m certainly going nowhere fast.

I’m tired today. I was up until almost 5am, sucking up as much information on lap band and my health insurance covering it as I could find. I suppose I should call the insurance company and get an updated quote/estimate/coverage information.

I hate the uncertainty. Hate it, hate it, hate it.