Insurance Question: What does this requirement typically mean?

[Redsfan19 37]

I plan to raise this with my surgeon's office when I meet with him on Thursday (and of course, eventually my insurance), but since there are a lot of people on the board who have successfully gotten insurance coverage for WLS, can others tell me how you have proven this to your carrier successfully:

− Evidence that attempts at weight loss in the 1 year period
prior to surgery have been ineffective

I know insurance companies vary and can change even from person to person regarding what they'll accept, but what have you all used to meet this type of criteria? Does it have to be something structured? Can it be loose? I'm really just curious about everyone's experiences.

PS - I also have this criteria "− Participation in a medically supervised weight loss

program, including nutritional counseling, for at least 3
months prior to the date of surgery.", but that sounds more structured.

[Pepper123 320]

Its means in the past year u have made attempts to loose the weight...and did not succeed...the last portion of your piece should be enough...good luck!!!

[SugarFreeMe 293]

Your first point means that you have evidence that you've tried to loose weight on your own within the last year. Have you gone to weight watchers, tried prescription meds thru your general practitioner and the like. The second point means that you will need to participate in a monitored program (most likely thru your surgeons office) for a 3 month period. This is typically done to show that your are fully committed and can stay focused on doing the right thing for yourself. It also helps you loose prior to surgery which makes recovery and the actual surgery easier. They are typical requirements for the majority of insurance companies. Your surgeons office will be very familiar with the requirements.

[Redsfan19 37]

But does this mean you have to try things you've done in the past all over again, or is it often enough to tell your dr all the things you've tried (I've done Weight Watchers countless times, Jenny Craig, meds, met with dietitians, etc.) and have them sign something for you acknowledging that? I'm mostly just asking so I can try and get some idea of how long all of these things might take me to complete if I decide to go through with it.

[2muchfun 8,927]

You're going to have to provide evidence(documentation) that you were on some kind of program such as weight watchers or some doctor supervised program and were unsuccessful. Insurance can be very picky over something like this if they want to be.

My insurance required this but only for 6 months and then they waived the requirement for everyone about my 5th month of supervised nut/doc visits.

[Miss Mac 6,262]

I had to provide documentation for two years of medical weight loss attempts and three months of a closely monitored specific program with a bariatric nutritionist. For the first part, my primary doctor ran a copy of my medical records for the previous two years, and I highlighted every mention of my weight and his recommendations for various diet changes. For the second part, the bariatric clinic has a nutritionist on board, and I had regular monthly visists (3) which she documented. That was good enough.

[B-52 7,113]

This is exactly what my 6 month medically weight loss program was.....

My insurance co. wanted, for the record, that I have attempted in good faith, traditional methods for loosing weight, and have failed...thus WLS being the last resort.

I told the staff every diet I have ever tried, and failed at....but they said the insurance would not accept that, because it was only my word, and that was not good enough..it had to be medically supervised by a MD, with accurate progress reports, graphs, etc. etc. and signed off by him/her.

So I had to sign up and do a 6 month program, supervised by a MD and staff....with weekly weigh-ins and counseling...it all had to be accurately documented and charted....

And just like every diet I have ever been on, I started out good, then leveled off when I started to cheat, then by the end of the 6 months I was gaining it all back again....voiding all the previous progress....

But there it was, in black and white...actually color graphs and pie charts....confirming that I sucked at dieting, and no matter what, I was a failure....THAT qualified me for WLS.

I read here all the time about people taking the 6 month diet program and being told that if they fail, they would not qualify for the WLS...to me that is bass-ackwards....if one could loose weight, why in the world would they need surgery of all things???

Edited October 15, 2014 by B-52

[Redsfan19 37]

I had to provide documentation for two years of medical weight loss attempts and three months of a closely monitored specific program with a bariatric nutritionist. For the first part, my primary doctor ran a copy of my medical records for the previous two years, and I highlighted every mention of my weight and his recommendations for various diet changes. For the second part, the bariatric clinic has a nutritionist on board, and I had regular monthly visists (3) which she documented. That was good enough.

@@Miss Mac, I saw in another thread that we have the same insurance, so I'm hoping I can use your experience!

[Redsfan19 37]

This is exactly what my 6 month medically weight loss program was.....

My insurance co. wanted, for the record, that I have attempted in good faith, traditional methods for loosing weight, and have failed...thus WLS being the last resort.

I told the staff every diet I have ever tried, and failed at....but they it was only my word, and that was not good enough..it had to be medically supervised by a MD, with accurate progress reports, graphs, etc. etc.

So I had to sign up and do a 6 month program, supervised by a MD and staff....with weekly weigh-ins and counseling...it all had to be accurately documented....

And just like every diet I have ever been on, I started out good, then leveled off when I started to cheat, then by the end of the 6 months I started to gain again...voiding all the previous progress....

But there it was, in black and white...actually color graphs and pie charts....conforming that I sucked at dieting, and no matter what, I was a failure....THAT qualified me for WLS.

I read here all the time about people taking the 6 month diet program and being told that if they fail, they would not qualify for the WLS...to me that is bass-ackwards....if one could loose weight, why in the world would they need surgery of all things???

Exactly, it seems really stupid. And a waste of money, since my insurance doesn't pay for medical weight loss or other types of weight loss programs. I saw an article by a bariatric surgeon as I've been researching these procedures arguing this very thing - why are we asking people who have accepted we have continually failed at this to prove once again they can't do it before we can get surgery?

[B-52 7,113]

Exactly, it seems really stupid. And a waste of money, since my insurance doesn't pay for medical weight loss or other types of weight loss programs. I saw an article by a bariatric surgeon as I've been researching these procedures arguing this very thing - why are we asking people who have accepted we have continually failed at this to prove once again they can't do it before we can get surgery?

It does sound stupid...but they want it officially on record that WLS is a last resort to traditional dieting....

I had to pay out of pocket....over $100 a week for the first 3 months, then every 2 weeks...by then we were scheduling surgery

My insurance would not reimburse, but I did use it as a tax write off with other medical expenses...

[jessiquoi 623]

my pcp wrote a letter stating that i met this requirement. my insurance company has a five year requirement of proof of obesity and weight loss efforts. he hasn't even been my doctor for that long, but he wrote that letter without me even asking.

any doctor that you've been seeing can do this for you. they always weigh you each visit, so they have your weight documented. it's worth asking, in my opinion.

[Rovobay 920]

OP, what insurance do you have? others with same program may be able to chime in. 1 year prior weight loss attempts for me were, myfitnesspal (I printed off my weight chart), and other various diets just writing them down with starting weight, time on diet, and ending weight.

I have BCBS Federal Employee Program

[amazon 579]

As far as I know, the questionnaire I completed for the WL center took care of any such requirement. It asked for this information going back 5 years. I did not have to provide "proof", just list everything I tried, when, and what weight I lost (if any).

I don't even know if my PCP had to supply anything...it appears that the center took care of everything.

I hope it's that simple for you!

[Redsfan19 37]

OP, what insurance do you have? others with same program may be able to chime in. 1 year prior weight loss attempts for me were, myfitnesspal (I printed off my weight chart), and other various diets just writing them down with starting weight, time on diet, and ending weight.

I have BCBS Federal Employee Program

I'm BCBS Federal too. The comments in this thread are raising my hopes that this could POSSIBLY be less time consuming then I feared!

[Jersrose43 837]

I think you're overthinking it. Don't stress it just go to the surgeon let the. Worry about it. Get the pcp or OB to write a letter and indicate your weights at various time periods.