Weight Loss Program documentation?

[xochtlem 54]

I have Anthem Blue Cross of CA and based on what they've told me over the phone and the medical policy they directed me to, I have to show documented attempt at non surgical weight loss for 6 months within the last two years.

So Anthem told me it could be WW receipts, or invoices for the medical weight loss program I used.

But the surgeons office Told me that invoices aren't good enough, and that they need to see that I was counseled on nutrition, the actual numbers of pounds lost, etc.

Does anyone know what passes as valid documentation for Anthem?

[ChefSaraKay 21]

I have United Healthcare but they required 6 months of medically supervised weight loss. I had talked to my primary care doctor a few times about weight loss and we tried a few things and I had talked to my endocrinologist about weight loss and I had a visit with her nutrition counselor. All that totaled to be 4 months of supervised weight loss since it was in my medical chart that it was discussed with my doctors and I was working to lose weight. During the process with my bariatric surgeon, I had to see a nutritionist 2 times and visit my primary care doctor for a check up and surgical ok along with sleep study, blood testing, and a visit with a psychologist. All this took about 3 months to do but the visits with my primary care and nutritionist counted because we discussed weight loss. I just had to make sure that i had visits in 2 different months (I was doing all of this in sept, oct, and nov) Once I completed all of my post op obligations, my surgeons office had all of the documentation needed to show 6 months of medically supervised weight loss and I was approved on the first submission to insurance. I just had my sleeve done on 12/28! I know that I wanted the surgery as soon as possible and didn't want to have to wait the months but you have so many appointments and tests that you almost need a few months to get it all done and mentally prep yourself for surgery. Hope this helps

[LessOfKevin 0]

I have Anthem Blue Cross of CA and based on what they've told me over the phone and the medical policy they directed me to, I have to show documented attempt at non surgical weight loss for 6 months within the last two years.

So Anthem told me it could be WW receipts, or invoices for the medical weight loss program I used.

But the surgeons office Told me that invoices aren't good enough, and that they need to see that I was counseled on nutrition, the actual numbers of pounds lost, etc.

Does anyone know what passes as valid documentation for Anthem?

What are "WW receipts"?

[xochtlem 54]

I have Anthem Blue Cross of CA and based on what they've told me over the phone and the medical policy they directed me to, I have to show documented attempt at non surgical weight loss for 6 months within the last two years.

So Anthem told me it could be WW receipts, or invoices for the medical weight loss program I used.

But the surgeons office Told me that invoices aren't good enough, and that they need to see that I was counseled on nutrition, the actual numbers of pounds lost, etc.

Does anyone know what passes as valid documentation for Anthem?

What are "WW receipts"?

Weight Watchers Receipts.

[Cape Crooner 589]

I had Anthem CA PPO and got approved in 5 days. I wrote up a 2 page document chronicling all my diet attempts over my lifetime. But the key was that I wrote it in the third person and gave my hospital a word version. I also included a scanned report from my PCP 7 years ago that stated that I was obese and prescribed a low fat diet. I also got a prescription for two other diet related treatments in the past three years and mentioned at as well.

[LessOfKevin 0]

Thanks! @@xochtlem

[hockeyfan7 249]

I was required to have 6 months of supervised weight loss for Anthem BCBS. My PCP just wrote a letter stating that I had tried Weight Watchers, Jenny Craig, Atkins, South Beach, seen a NUT, and that she was agreeing that I had not seen success with anything. That was good enough for the insurance company.

[LessOfKevin 0]

I have Anthem Blue Cross of CA and based on what they've told me over the phone and the medical policy they directed me to, I have to show documented attempt at non surgical weight loss for 6 months within the last two years.

So Anthem told me it could be WW receipts, or invoices for the medical weight loss program I used.

But the surgeons office Told me that invoices aren't good enough, and that they need to see that I was counseled on nutrition, the actual numbers of pounds lost, etc.

Does anyone know what passes as valid documentation for Anthem?

What are "WW receipts"?

Weight Watchers Receipts.

THANKS!!! Kev.

[2goldengirl 2,076]

I have Anthem Blue Cross of CA and based on what they've told me over the phone and the medical policy they directed me to, I have to show documented attempt at non surgical weight loss for 6 months within the last two years.

So Anthem told me it could be WW receipts, or invoices for the medical weight loss program I used.

But the surgeons office Told me that invoices aren't good enough, and that they need to see that I was counseled on nutrition, the actual numbers of pounds lost, etc.

Does anyone know what passes as valid documentation for Anthem?

It isn't Anthem so much as your medical group or IPA. They're the ones who actually review and approve your surgery. I would say (I do this as part of my job) that no, receipts from WW aren't sufficient, but copies of your weekly book show you consistently showed up for meetings. Additionally, if during that time you met with your PCP and discussed your weight loss efforts, that also helps.

The goal here is to show that you've made an honest effort and show consistency in adhering to a weight loss program for more than a month or so at a time - because that 's what you need to be successful with the surgery.

I would call your IPA or Medical Group and ask to speak with the person who reviews bariatric surgery requests. Talk with them directly and you'll get the best answer. People who answer 800 numbers have to answer every question under the sun and they aren't part of the review process.

Edited January 18, 2016 by 2goldengirl

[xochtlem 54]

I have Anthem Blue Cross of CA and based on what they've told me over the phone and the medical policy they directed me to, I have to show documented attempt at non surgical weight loss for 6 months within the last two years.

So Anthem told me it could be WW receipts, or invoices for the medical weight loss program I used.

But the surgeons office Told me that invoices aren't good enough, and that they need to see that I was counseled on nutrition, the actual numbers of pounds lost, etc.

Does anyone know what passes as valid documentation for Anthem?

It isn't Anthem so much as your medical group or IPA. They're the ones who actually review and approve your surgery. I would say (I do this as part of my job) that no, receipts from WW aren't sufficient, but copies of your weekly book show you consistently showed up for meetings. Additionally, if during that time you met with your PCP and discussed your weight loss efforts, that also helps.

The goal here is to show that you've made an honest effort and show consistency in adhering to a weight loss program for more than a month or so at a time - because that 's what you need to be successful with the surgery.

I would call your IPA or Medical Group and ask to speak with the person who reviews bariatric surgery requests. Talk with them directly and you'll get the best answer. People who answer 800 numbers have to answer every question under the sun and they aren't part of the review process.

I'm not even sure who or what my Medical Group/IPA is. I just know that I spoke with the pre certification group at Anthem to ask them for their requirements. How would I find out who my medical group/IPA is?

I'm starting to get annoyed with the whole ins process, and I'm contemplating just doing self-pay in Mexico so I can do it on MY schedule and not the insurance company's schedule. I have a feeling they're going to make me wait the entire 6 months, and then that still doesn't guarantee approval and I'll be so pissed if they didn't approve me after all that. Lol

[2goldengirl 2,076]

Firt, I am presuming you have an H M O plan. Look on your insurance card; your PCP's name and medical group's name should be on there.

I can understand why you'd be tempted to go to Mexico and do this on your own timeframe, it's a purely personal decision. I'd rather same any $ I might have spent doing that because I will more than likely want plastic surgery in a couple years.

Approval isn't a mystery. If you meet the criteria, you get approved. It really IS as simple as that.

So. Have you participated, really done the job, for six months in the past two years? Do you have a BMI 40 or above? If your BMI is < 40, do you have any comorbidities?

[xochtlem 54]

I don't have an HMO. I have a PPO.

Okay, for whatever reason my response was censored? ???? I don't have a Health Maintenance Organization. Lol

[xochtlem 54]

My BMI is 41ish, no comorbidities. I've done so many diets, I could probably write winning diets for other people. Lol! Last year I did a "medical weight loss program" with a company for about 6 months, where all they really did was monitor your weight and prescribe phentermine. I lost about 20lbs and as soon as I stopped the phentermine I gained it lol back plus some. I'm at my biggest now, around 257-260 at 5'6", and my depression is getting worse. I work from home, which kind of makes isolation easier and depression worse. I just really need this.

I say I need to do it on my own timeline because I can't fathom waiting yet another 6 months, only to Celebrate another birthday still fat and still hating my body, and still trying to get it back to what it used to be.

This is the year I plan to focus on myself, because I've focused on others for so long that I lost myself in the process. A bad relationship wasn't helpful, either. And my daughter is an amazing, fit gymnast and I just want to be a better role model for her. I want her to love her body and take care of it, and I need to lead by example.

I figured that if I wait for insurance, I'd pay no more than $3k out of pocket. I have an FSA that will cover $2550 of that. If I pay for the procedure in Mexico, I know I'd pay more but I feel like at least I have more control in the timeline.

And of course, a part of me is just being impatient, wanting almost instant gratification. When I want something and have done the research, I want it now and just hate waiting.

My therapist understands, but she's not too keen on me leaving the country for this either. However I always make sure I research everything I do, so if I do choose that route I will be confident in my decision.

[xochtlem 54]

And part of my concern since I have no comorbidities, is if I lose enough weight during the six months to put me under 40 BMI, will the insurance company still approve me?

Because then I'll be really mad. Lol

[2goldengirl 2,076]

OK, that explains the "no medical group" bit, you aren't tied to one with PPO, only H M O.

Do you have records from the 6 months you did with the phentermine clinic? Because that should satisfy the 6 month requirement right there.

I wonder if your FSA won't also cover Mexico?

A lot of us got into obssityland from not dealing well with frustration, and/or from wanting instant gratification. Keep aware of this part of your thinking as you proceed. And please don't hate your body, no matter what size it is. It carried and birthed your daughter and has carried through your entire life. It, and you, deserve more respect than that.