Insurace Question

[melonpie05 99]

Non-compliance - For purposes of this policy, non-compliance is considered to be: • Initial weight loss followed by re-gain without participation in the complete

medical weight management program

I took that from my insurance page and wondering exactly what it means I got sonny answers online and I thought maybe you guys would know?

[melonpie05 99]

It seemed to me what I read the medical weight management plan is something more long term when my insurance was only requiring a 6 month supervised diet I'm starting to get really nervous and don't want to be denied

[melonpie05 99]

BMI equal or greater than 40 and less than 55:

• Must have one (1) of the following co-morbidities:

o Symptomatic sleep apnea (apnea-hypopnea index [AHI] >10) or Chronic

Pulmonary disease requiring at least one (1) medication or Positive Airway

Pressure (PAP) devices (e.g. pulmonary hypertension, Pickwickian syndrome) o Significant cardiovascular disease, disease (eg.coronary artery disease (CAD)

under treatment, right ventricular hypertrophy (RVH) or left ventricular

hypertrophy (LVH), cardiomyopathy

o Hypertension requiring triple therapy

o Diabetes with HbA1C > 8.0 on one or more medications. OR

• Must have participated in a physician supervised weight loss program which includes:

o Compliance with attendance >80% of classes

o Weight loss program completed within two years of the request for surgeryNutritional counseling

o Exercise

o Behavior modification components.

[cnocon 36]

That is a lot of unclear information. If I were you, I would call the office of your surgeon and see of they have anyone on staff to help patients comply with their insurance requirements, let alone help uncover what they are exactly. Insurance providers are terrible at clearly and consistently explaining how to qualify for benefits.

Don't rely on answers in this forum or online- find an insurance advocate or professional to help you. You shouldn't have to do this on your own.

[melonpie05 99]

Yeah it I'd very unclear to me but it right I do just need to call and get a for sure answer of what is expected thanks

[cnocon 36]

Good luck! I'm cheering for you!

[BBdoodle 483]

You need to have your doctors office insurance coordinator to get the specifics, they are trained and know all the in and outs of getting approved. Good luck

[melonpie05 99]

Thanks I hope all goes well

[LosingItForMe2011 320]

melonpie05 - have you completed the 5 months or was it a week short etc? My insurance wanted a 3 months supervision stint after having already approved the time frame the first time when my surgeon submitted the paperwork. They denied me the first time because they wanted weights for the past 4 years. Then when they were given that they denied because of the 3 months supervision they said was short by a few weeks. My surgeon fought that stating they approved it the first time. So we won that battle but, then it came down to my PCP's letter not stating the exact wording of "medical release for surgery". Turns out my PCP was on vacation so my surgery had to be delayed. I saw my PCP and was then approved after she wrote yet another letter stating the medical release. It's amazing what some insurances make us do but, folks are right...your surgeon's office knows what needs to be done. Talk with them and don't be afraid to call your insurance company yourself. I do medical billing for a living and tell my patients that all the time. Sometimes a patient calling gets things moved along faster and some denials approved. Call your insurance and ask them straight out what those words mean and what needs to be done to correct it and get the approval. You'd be surprised how much further a patient can get than their doctor sometimes. Good luck! I was denied twice and finally have my date...so it possible!

[melonpie05 99]

I am on visit number 3 of 6 so half way there I only have the BMi but I gained 5 pounds and scared to death there going to say it was no compliance but I hope they will take start and end weight and that's the only number that matters so we will see when I call tomorrow and get there definition of non compliance Bc in another section compliance was only considered completion on 80% of suprovosed diet do its all very confusing so I just need to call and get it straight

[TinyMamiOf3kids 1,280]

All the best to you girl

[melonpie05 99]

Talked to my insurance company wasn't very informative all they told me was I had to do the 6 months then my dr would submit it and wait for approval

[melonpie05 99]

I tried to ask question about gaining and stuff and he just said its all a person to person basis

[ladyspl 161]

Ugggghhhh! Sounds like the bs I got from calling my ins!. Called 3x's asking for specifics and all they told me was 5year history and surgery at a center of excellence. Went to initial consult and was told a laundry list of requirements. So don't get discouraged, just get calling! LOL call anybody and everybody! LOL best of luck!