6 Mos. Medically Supervised....

[Krunchy Girl 0]

Hi all!

First of all, I'd like to say thank you to all who have posted and shared their WL journey. I have been lurking here gleaning as much info as possible. I guess it's time I share!

I am 53 years old. With a BMI of 40 and several co-morbidities. I have tended to be a little heavy all of my adult life, but never as extreme as in the last 10 years, in which time I have gained 100 lbs.

At this time I have attended 3 seminars.....OK, I am a slow learner. The first one- I thought "oh how extreme!, If I can't control what I eat now, how could I with WLS". And, "My Dr. would never go along with it". And, "I could never afford it!" The second seminar was after much research and a hospitalization over my heart-resulting in my PCP recommending WLS. That is when I discovered that the closest WLSC (one hour away in Southern OR) was not COE rated, which is a requirement of my insurance. The third seminar was a webinar for WLSC 4 hours away, to the south in Chico, CA. I am willing to go the distance for surgery and fills, however they don't have any type of "medically supervised diet, exercise or behaviour modification program" which is a requirement by by insurance plan (GEHA). Six months within the last 12 months I have to have documentation of the "medically supervised" diet and exercise.

I saw my PCP at end of November (when he recommended WLS), however hadn't been to see him at all in previous 12 months, so have to start from then. I also saw him in December, so that I could add that to the record, but he really doesn't know what he is supposed to be documenting. He said that if he codes for "obesity" the insurance doesn't pay. I may have to just self-pay for these visits so the insur. will cover surgery. I have seen others refer to the 6 month "medically supervised diet " but never any specifics, like how do I document this. I really am ready for this surgery now, am willing to go through the 6 months of diet, but want to make sure I am doing it right so the Insurance covers! Also, would like to have an actual "program" so that I can feel some progress! Any ideas out there? (Thanks for listening to me babble on!)

[~*~Rachel~*~ 2]

Hi I had the same problem. My surgeon was only an hour away but by the time you spent the money for gas parking and co pays it can add up. So I went to a doc and the box that made appointments and talked to a doctor there. She became my PCP and I went to her for 6 months. My insurance also did not cover anything by obesity so I cheated the System. I became a hypochondriac each month I had a different problem each month. I got my blood pressure under control so that was at least two months getting the meds and going back to see if they worked. The next month I had problems sleeping and a ear infection and so on she may think I am a whinny thing but at least I got her to document my weight and that I was "attempting" a diet. So that is how I worked the system. Hope that gives you one idea.

[~*~Rachel~*~ 2]

Hi I had the same problem. My surgeon was only an hour away but by the time you spent the money for gas parking and co pays it can add up. So I went to a doc and the box that made appointments and talked to a doctor there. She became my PCP and I went to her for 6 months. My insurance also did not cover anything by obesity so I cheated the System. I became a hypochondriac each month I had a different problem each month. I got my blood pressure under control so that was at least two months getting the meds and going back to see if they worked. The next month I had problems sleeping and a ear infection and so on she may think I am a whinny thing but at least I got her to document my weight and that I was "attempting" a diet. So that is how I worked the system. Hope that gives you one idea.

[grmadeb01 0]

i have no ideas on your matter at hand, but you and i are in about the same boat. ha ha, i just have gone to one seminar, i do not have to have the 6 months supervision, but the surgeon place that i went to the seminar handed out a sample letter that they want my dr to write to my insurance. this sample letter sounds very, very, very urgent to have the surgery as soon as possible in order to save life. i am going to take this letter to my dr tomorrow, i also have to have 5 years of past medical records to show my weight gain and medical problems i havel, so far that is all i have to do. if it is possible perhaps we can email back and forth, and maybe i can find a way to copy this sample letter to you and you can take it to your primary doctor. i know that this whole process is not going to happen with out your drs. help. so i would start with your primary, and perhaps they can fine some sort of supervised diet place that can help, like weigh watchers or something along those lines that would be ok to attend that is close to your house. I hate to say this, if we could all conntrol and loose weight in the 6 months, then we would not need the surgery..doesnt make sense to me with the insurance thought process....but you have to jump thru their hoops in order to get them to pay.

i hope you well in your progress.. keep in touch i am a bit computer illertrate and how do to alot of things on the computer so email me and we can stay in touch

[cheryl2586 3,053]

Usually you need a Dr to have documented for at least two years about your weight and comorbidities. Once that happens they will write a letter of medical necessity and submit it to your insurance company or to the surgeon. If you dont have a lot of documentation or have had a BMI of 40 for at least two years they wont approve it. You have to have a stable dr who has taken care of you for quite some time if not then you need to get one and start going every single month to get the ball rolling. Complaints of being tired, back pain, heartburn, then yes test after test. Its just the way it is. Its not about cheating the system. Weight loss surgery should be done on people with comorbidities if you are a normal healthy person with just a weight problem then they are going to make you document every single diet you ever tried since you have been overwieght and you have to have dates for these diets. Its not easy but it has to be. Its not cheating the system its doing it right so you dont run in to problems later down the road

[Krunchy Girl 0]

Thank you all for your support! Rachel, that is very clever about "finding" a reason to see dr. every month! My insur. company benefits state that I must have documentation of 6 months of "medically supervised diet and exercise" that occurred in the last 12 months. But I've been afraid that I won't have the details quite right. I have seen so many post of people denied because they or their dr. missed some little detail in the documentation. Unfortunately, while I have gone to the same Dr. for many years- haven't been at all in last year (until this past November anyway). My co-morbidities and BMI is well documented as being greater than 40. I finally got to talk to the bariatric surgery specialist at my insurance company (GEHA). As it turns out, I do have to have 6 months of visits (at least 6 visits total) that must have occured within the last 12 months, where the Dr. actually DOCUMENTS that we discussed diet and recommended (kcal/day) as well as exercise and specific routine (length of time & number of times/week). I think that this is an important thing that even if the dr. discusses it with the patient it often isn't documented as such. My PCP told me that they often don't put the code for obesity because the insurance doesn't like to pay for those visits. Seems like the timing of all of this is very important, because the Nut, Psych, Surgeon consult, approval has to fit into a six month period, after 6th visit (month) documenting diet & exercise and before 12th month ends at which point the first month's diet & exercise doesn't count anymore! No more indecision for me!