Documented Proof of Failed Medical Weight Loss???

[cindylew718 0]

This is my first post and I am so grateful to all of you for your great information and advice.

I've been researching for months but have recently decided I wanted to do the Lap Band and am now in "on a mission mode". I'm going to a Intro. Seminar on Saturday and have my one-on-one Dr's appt. this Wednesday. I know that's a bit out of order but I called today and the surgeon had a cancellation that worked with my schedule so I jumped on it.

Here's my major concern...DOCUMENTED PROOF OF FAILED MEDICAL WEIGHT LOSS. "Failed weight loss" could pretty much be the title for my biography but I doubt I'm alone in that I have never involved my Primary Care Physician (or any doctor for that matter) in that aspect of my life.

So what now...I've been fat all of my life with short and intermittent periods of thinness. I've spent the last two years of my life creeping up the scale to 240. I'm so psyched to start this process and now someone is going to tell me they have to observe me for another 6 months while I attempt once again to lose weight??? Are you kidding me?

How do you guys handle this and where are you all coming up with this "documentation" so to avoid this 6 month waiting game?

I have Amerihealth P.O.S...does anyone have a clue as to their policies???

Any feedback would be so appreciated.

[cwm812 11]

I hope someone has a better response for you, but that's what I had to do, even though I did involve my primary doc for one of my diets. At my first appointment, I gave a written detailed list of my "attempts" and their dates and durations. Even though this list spanned 30 years and had some documentation, the insurance company felt I should give it another 6 months. It was incredibly silly, but in the end I got my band and they paid for it.

Cindy

[BetsyB 9]

For me, this amounted to providing a list, to the surgeon, of past attempts (or even successes---though as we all know, those tend to be followed by regaining) at weight loss. I am sure mine was far less than comprehensive; I couldn't begin to enumerate every attempt I've made!

The words sound intimidating, but really---I think you will find very few obstacles to being banded. If you're covered, and meet the BMI (and/or possible comorbidity) criteria, it will be deemed medically necessary.

But YES--if your insurance so specifies, you WILL have a period of weight supervision by the surgeon's group. (This is independent of any documentation you provide; my PCP had documentation, and I had documentation from WW memberships--and that didn't matter. What matters is the time frame stipulated by your insurance contract.)

My period of supervision was three months--I visited monthly and though I was impatient to get the ball rolling, it really was a great opportunity to get my questions answered, become more comfortable with my doctor and his staff, and so on.

Really, they keep you pretty busy with other things during the waiting period---things like clearances by a cardiologist, pulmonologist, and psychologist. You might require a sleep study or cardiac studies beyond an ECG. You might find yourself having pulmonary function tests. You might find yourself in the office of another -ologist. These fill up the waiting time quite a bit.

It's frustrating---but the time does pass, and soon you will be banded. By the time you are, you will be confident about what's ahead---and your doctor will be confident that you're a candidate who will do well.

I'll be okay :tongue_smilie:

Edited February 23, 2010 by BetsyB
because I'm not yet caffeinated, and therefore cannot think clearly enough to write clearly

[ElizabethS 0]

Hey you do not have to fret on this just be prepared. Here is a little of what i was asked. They asked my weight as i remembered it at 10 years, 5 years and then like 3, 2 1. Asked me the lowest also. I was prepared with all the weight loss plans i tried and failed, they asked how much i lost and how much of it gained back it was like a chart i had to fill out but i wrote down all my attempts EVERYthing even the silliest pill or dumbest diet ever and put it ALL down in its entirety. My BMI and the fact that I had obstructive sleep apnea was a big approval with insurance for me. I think you just need to show how many attempts you made. (its what i had to do) I do know someone who didnt provide that info and had do a 6 month proof that they could not lose weight. Just be prepared. You will go over that on the psych and nutrition visit. I just went thru it last month or so. I was banded 2-3-10 feel free to ask while its fresh in my mind lol i am 52 and sometimes we forget stuff lol :tongue_smilie:

[ElfiePoo 109]

It will all depend on the insurance company. I have BC/BS of MI and all I did was list my 40 years of weight loss attempts with just the year attempted and an approximately of how long I lasted on each attempt. It was a very rough list.

However, about 15 years ago, the same BCBS required *proof*. In other words, documentation that I actually attended WW meetings or worked with a doctor. Without that, I would've had to do a 6 month supervised diet.

This time I didn't. I guess they finally got smart and realized that someone isn't fat for 40 years with zero attempts to lose that weight.

My fear was that they'd look at the fact that I lost 70 pounds 6 years ago and never put it back on and refuse the surgery because I "obviously could lose the weight and keep it off".

.

[bandmeimready 0]

It is so hard to wait. I have BCBS of Alabama. They require a Dr supervised diet for 6 months which really ends up being 7 months. It is a bummer! I went to the seminar last Saturday and have my first appointment with my primary about my weight loos today. I know exactly how you feel. You finally make a decision after struggling for so long to go ahead and get banded and then you are told it is going to be awhile! Stay strong! I have a feeling it will go by faster than we think!

[illuminationlady 7]

I, like you, could make this title the title of my life. However, I was required to show some sort of proof of failure. I went to Weight Watchers (because it was the cheapest) for 3 months and that did the trick. Hope this all helps!!! Best wishes!! Keep us posted.

[kll724 3,055]

I had so many failed weight losses. When I documented mine with the Nut, I could go all the way back to TOPS in high school. But, then I was considered the "skinny" girl in TOPS. I was only a little "chubby". Over the years, I probably gained and loss 200+ lbs. That is why I wsa glad to get the band. I have faith that this will do it for me. I have loss 67 lbs, 34 of which I lost in the 6 months before banding. I have had the band since 10/30/09, but count my weight loss back to April when I 1st went to the seminar that changed my life.

Welcome to a new life with Lapband. Karen

[btrieger 21]

Aetna required proof of my weight, not weight loss for 2 years.

I got the transcripts from a doctors visit in March of 2008 and my bariatric surgeon weighed me in September 2009.

That was enough for Aetna.

[RavenClaw779 2]

It really depends on your insurance carrier - in fact I have heard of incidences where a patient has begun the WLS process under one insurance carrier's parameters, met the qualifications, deductible, what have you then their employer change carriers and they're back to square one OR find that they are able to proceed much faster than with the prior carrier.

Even within carriers the plans very. I'm with BCBS or MA through my husband's employer. It's a PPO. The BCBS of another state or even a BCBS HMO can be totally different.

*It's always a good idea to either have a hard copy or PDF on your desktop of your current plan - not just the highlights, but the fine print and exclusions.

*You can call the customer service at your plan and get a different answer every time - and it may not be the right answer. You need to be able to reference your plan specifics and be prepare to file an appeal if necessary...and not just for this procedure. Carefully review your EOB's(Explanation of Benefits) - I can't tell you how many times I've had to question a denial or incorrect payment only to get the "Whoops - My Bad" type of response. Saves me a ton of money.

Here's a cut and paste of my plan's baratric coverage as an example:

Charges for surgical services for morbid obesity, including gastroplasty and gastric bypass surgery only if:

1. prior authorization is received from the claims administrator; and

2. presence of severe obesity that has persisted for at least five (5) years, defined as either:

a) body mass index (BMI) exceeding 40; or

:tongue_smilie: BMI greater than 35 in conjunction with any of the following co-morbidities:

i. coronary heart disease; or

ii. type 2 diabetes mellitus; or

iii. clinically significant obstructive sleep apnea; or

iv. medically refractory hypertension (blood pressure > 140 mmHg systolic and/or 90 mmHg diastolic despite optimal medical management); and

3. patient has completed growth (18 years of age or documentation of completion of bone growth); and

4. patient has attempted weight loss in the past without successful long-term weight

reductions; and

5. patient has participated in a consistent program that is physician-supervised with integrated components of a dietary regimen, appropriate exercise and behavioral modification and support; and

6. an evaluation has been performed by a multi-disciplinary team with medical, surgical, psychiatric and nutritional expertise, and

7. for patients who have a history of severe psychiatric disturbance (schizophrenia, borderline personality disorder, suicidal ideation, severe depression) or who are currently under the care of a psychologist/psychiatrist or who are on psychotropic medications, a pre-operative psychological evaluation and clearance is necessary in order to exclude patients who are unable to provide informed consent or who are unable to comply with the pre- and postoperative regimen. Note: The presence of depression due to obesity is not normally considered a contraindication to obesity surgery.

Edited February 23, 2010 by RavenClaw779
typo

[xavier 153]

Just to make you all feel better for all this crazy insurance stuff...Mine said there was no way they would pay because I wasnt fat enough (hello!?!) and had no comorbidities(yet!!) ...so I had to write a big check to my surgeon! It was worth it of course but if I could do a six month diet and get back all that cash...well you know!

[kfstinson 0]

I think the point everyone is making is that it really depends on insurance. Insurance companies want to pay as little as possible. I began this process in December 09. I attended the orientation meeting with the surgeon. I met with my PCP who agreed with my decision, had my psych. eval., meeting with nutriontionalist and 1st meeting with surgeon. On Feb. 12, my doctor's office called telling me that my insurance was changing on Feb. 15 to the waiting 6 months under a doctor supervised weight loss plan, and other insane things that I've already done . I freaked! I work for the State of Virginia and my local agency HR director neglected to forward that E-mail to us!!!!! Luckily I was 'grandfathered' in. I have a problem with the new rules. Don't these insurance companies know that most of us have been through so many weight loss programs, support groups and other things? I was very successful with Weight Watchers, all 4 times in the past 3 years I've been on it. But I just can't keep the weight off. For most of us bariatric surgery is a big decision. I know I haven't come to banding on the spur of the moment.

[Karlzmom 1]

In addition to my medical file, that did include multiple conversations with my PCP, prescription meds for weight loss, etc. I also went through my files and came up with all my credit card statements with WW dues, Jenny Craig meals, gym memberships, etc. My coordinator said she had never seen a person so organized....:laugh: Seriously, My "packet" was over 70 pages total and clearly demonstrated a long term, active attempt to lose and maintain my weight. When all was said and done, the coordinator said that she had never seem my carrier approve a request as quickly! Unfortunately, now the hold up is my calendar.....:biggrin:

[gatlingirl 0]

My insurance requires 6 months of Family Physician "diet". I am 4 months in and it's not going that well. But it has went by really quickly and they will keep you busy doing other things to get ready for your surgery too. I had to do an "excercise" clearance with the local wellness center. Then I had to do the psychological exam.

I was a little bummed about waiting another 6 months but I've been fat for more than 20 years so another 6 months wasn't that bad.

Good Luck with your journey. :biggrin:

[Manda87 3]

Like everyone says, it does depend on your insurance. My insurance didn't require a 6 month diet. My surgeon just submitted the paper work and a little over a week, I got approved.

Like another person said, the surgeon's office will keep you busy with pre-op tests like upper GI, chest x-ray, EKG, etc. If you do have to have a diet, it will go by quickly. :biggrin: