I Have First Health Network Ppo And Not Sure What This Means

[fat2kim 5]

Hello Friends! I am a 40 yr. old female, 275 and 5' 3". I have been seeing my doc for 3-4 and for the past 2 or 3 yrs he has me on lortabs to control my back pain and I have been on Blood Pressure Meds for 15 yrs. I have severe leg, knee and back pain. He has been documenting this all due to morbid Obesity and has on my file that it is my Main medical Prob. he and I have been talking about weight loss and I have been doing Medifast, Slimfast, High Protien low carb type diets, WW, Chitosan...you get the picture, Ive tried lots since I have been obese which has been at least 18 yrs. When I went in to see him on his request last Mon. we sat and talked about all my efforts and as I am telling him what all I have done he is typing as he usually does. He seems to take down every thing I say so i have no doubt that he has my weight loss efforts documented in there from the last 3-4 yrs. Anywho, I ask him about Lap band, I tell him I feel that I need the restriction to go along with the eating plan i have done so many times. I think it will be the missing piece of the puzzle for me. To make a long story not so long, he agrees that it is a great option and wants to write a letter of recommendation to my insurance and submit all the paper work and also refer me to Dr. he knows that does lap band surg. Here is what my policy says about WLS and keep n mind, no one at the insurance company knows what it means, so they say and I spoke to 3 people, so maybe you can shed light on it for me..Its an exclusion with exceptions

"

weight reduction except for the Medically Necessary surgical treatment of:

endogenous obesity including but not limited to metabolic factors and obesity due to hypothalmic lesions;

or

exogenous obesity if: a diagnosis of Morbid Obesity is given and a separate medical condition is present

which is aggravated by obesity (e.g., hypertension, diabetes mellitis, alveolar hyperventilation, chronic

back conditions, varicose veins, etc.);

for surgical treatment of Morbid Obesity the Covered Person must be:

twice his ideal weight;

demonstrate inability to control weight through diet over a minimum of a five-year period documented by a

Doctor’s medical records; and

must suffer from a documented separate condition which is aggravated by obesity;"

Any IDeas? Does this mean I have to be on a diet for 5 yrs or just need 5 yrs documentation of being obese and have tried dieting? Thanks for your Help in this. Im so thrilled to possibly get this oppportunity to finally see a light at the end of this very dark tunnel!!

[DeAna N 229]

I believe you just have to show that you have had weight issues for 5yrs you PC DR would be a good source for the requirement. Good luck

[fat2kim 5]

Thanks so much for your imput. I sure do hope your are right! I have that for sure. Good luck to youas well!

[honk 780]

Looks like you have to be twice your correct weight (if you should weight 130 pounds for your height and you way 260), and have a co mobidity like high cholesterol, blood pressure, etc.

[fat2kim 5]

Yeah i got that part I was just confused on the inability to show weight control over a minimum of a 5 yr period and be documented in a drs. notes. Does this mean I need to diet for a minumum of 5 yrs under a drs. supervision or just have proof that my weight has been obese for 5 yrs?

[fat2kim 5]

okay here is an update just for info sake....I called pre certification dept at my insurance co to get the exact requirements and here is what they said...Need to be over 40 bmi with a co morbidity, need to have 5 yrs of dr. records proving your weight has been obese, you must have 6 months of weightloss attempt under dr supervision with dr noting in file or 2 3 month attempts. ww does not count. must have phsyc eval and dietitician eval.