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Gastric Bypass and Your Insurance, page 9
A 12-page report about gastric bypass and your health insurance
©2005 Jonni Good
“Medical Necessity” – What it Means
If you read your benefit booklet carefully, you will usually find a list of definitions. You will probably find “medical necessity” listed, and the definition probably contains the following words: “the plan determines...”
What this means is that your insurance company decides what is medically necessary, for the purposes of determining if they will pay for a treatment or procedure.
This does not mean that they tell you, or your doctor, what treatments you need. They can only tell you what they are obligated to pay for. This may seem contradictory, but for the purposes of health insurance, “medically necessary” may not mean the same thing that your doctor thinks it means.
In most cases, your insurance company will have a specific medical policy that has been created to determine if a treatment is medically necessary, under the terms of their policies. These medical policies are actually an extension of your benefit contract, because they determine whether or not certain procedures are covered, and which specific criteria must be met.
Written medical policies are needed to assure the insurance company (and state regulators) that all customers are treated fairly and alike. These medical policies are usually available to doctors, and may also be available to you, on the insurance company’s website. If gastric bypass surgery is covered on your policy, you can read through the medical policy with your doctor to see if you meet the insurance company’s criteria for benefits.
If your insurance company doesn’t make their medical policies available on their website, call them and ask for a copy.
Most insurance companies base their gastric bypass medical policies on the National Institutes of Health guidelines. According to these guidelines:
“You may be a candidate for surgery if you have:
• A body mass index (BMI) of 40 or more—about 100 pounds overweight for men and 80 pounds for women
• A BMI between 35 and 39.9 and a serious obesity-related health problem such as type 2 diabetes, heart disease, or severe sleep apnea (when breathing stops for short periods during sleep)
• An understanding of the operation and the lifestyle changes you will need to make. “
Many insurance companies will also require that you have a documented record of having tried more conservative treatment, such as diet and exercise, for a specific period of time, and you doctor must state that this treatment has not worked. They may also require all gastric bypass surgeries to be done at an approved clinic.
It is important that both you and your doctor understand the medical
policy before you ask your doctor to submit a pre-authorization request.
Next Page of Gastic Bypass and Your Insurance Report
New research shows that low-calorie diets can cause food obsessions and binge eating. They can even make sugar addiction worse. No wonder most people end up fatter than they started when they try to lose weight with a low-calorie diet.
The answer? The New Craving Control Diet.
Lose 3 to 5 pounds a week without surgery, starvation diets or dangerous appetite suppressant pills. Enjoy the satisfying, delicious diet that controls your appetite naturally, reduces food cravings, and helps burn fat faster.
Finally - Fitness Without Pain:
Have
you ever purchased exercise videos you couldn't use because the exercises
were too strenuous or caused you too much pain? If so, I found the perfect
fitness program for you.
It's called the "Runner's Yoga" program, but it's definitely not just for runners.
These specially-selected yoga exercises are easy to learn, and take only 30 minutes for a full workout. They firm up your muscles, give you greater flexibility, and help calm the mind so you can concentrate better during the day.
And all without any pain at all. In fact, it can even help reduce pain if you now suffer from injured knees or joints.
To learn more about this new fitness yoga program, click here.
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