6 month supervised diet question

[Hhs1078 3]

Hello,

I am meeting with my Dr on Monday and am just curious if anyone with BCBS MN had a supervised diet program from the past serve as a suitable attempt at weight loss. I did a Dr guided program that lasted a year, but that was 2 years ago. Anyone have similar circumstances that served as approval criteria? I just don't want to do something over again that I already know has failed and is adequately documented.

Also, my BMI is 38. Comorbidities are asthma, hyperlipidemia, impaired fasting glucose, djd in r knee with rec to have knee replacement, depression & anxiety.

[LeaninLanc 83]

I also have BCBS MN. The regulations are rather specific on the 6 months and it must meet specific criteria. I had BCBS MN email the specific criteria. I attempted to see if several years of Weight Watchers would work but there didn't seem to be a way around this standard. Good luck to you. I'm 12 days post op with first doctor appt last July.

[Hhs1078 3]

Do you recall specifics? The program was done by the dieticians and MDs which are also part of the bariatric surgery team at the hospital I would have surgery. It is a top rated Bariatric surgery facility.

[LeaninLanc 83]

Unbelievably after keeping the BCBS weight loss surgery criteria in my VSG folder since May 2016 I just discarded it last week. Perhaps it will meet the criteria, most likely depends on their time limits. So sorry I just pitched that. If you call the BCBS MN customer service number they will definitely be able to answer your ? Best wishes!

[Heres2SecondChances 31]

Here is a copy of the policy from BCBS MN that I have:

Policy Position Coverage is subject to the specific terms of the member’s benefit plan.

I. Adult Patient Selection Criteria

• The surgical treatment of morbid obesity may be considered MEDICALLY NECESSARY for patients 18 years of age or older who meet ALL the following criteria:
  • Body mass index (BMI) of ONE of the following:
    • BMI of ≥ 40 kg/m² OR
    • BMI of 35 kg/m² to < 40 kg/m² with AT LEAST ONE of the following comorbid conditions:
      1. Hypertension refractory to standard drug regimens; OR
      2. Cardiovascular disease; OR
      3. Type 2 diabetes mellitus (HbA_1C of 7 or greater, or requiring medication); OR
      4. Obstructive sleep apnea requiring continuous positive airway pressure (CPAP) or other related treatment; OR
      5. Obesity-hypoventilation syndrome (OHS); OR
      6. Pickwickian syndrome (a combination of OSA and OHS); OR
      7. Nonalcoholic fatty liver disease (NAFLD); OR
      8. Nonalcoholic steatohepatitis (NASH);

  AND

  • Patient meets one of the following in order to improve surgical outcomes, reduce the potential for surgical complications, and establish the patient's ability to comply with post-operative medical care and dietary restrictions:
    • Over the past year prior to surgery, the patient has actively participated in an organized multi-disciplinary surgical preparatory regimen with a substantial face-to-face component of at least 6 visits within a 6-month time-frame meeting all of the following criteria:
      1. Behavior modification program supervised by a qualified professional; AND
      2. Consultation with a dietician or nutritionist; AND
      3. Exercise regimen (unless contraindicated) to improve pulmonary reserve prior to surgery, supervised by exercise therapist or other qualified professional; AND
      4. Reduced-calorie diet program supervised by dietician or nutritionist

    OR

    • Prior to surgery, the patient has actively participated in a nutrition and exercise program with a substantial face-to-face component that meets all of the following criteria:
      1. Program is supervised by a physician, physician’s assistant, nurse practitioner/advanced practice nurse or registered dietician; AND
      2. Participation takes place for a cumulative total of 6 months or longer in duration and occurs within 1 year prior to surgery; AND
      3. Components of the program include visits with dieticians and/or nutritionists,
         • Community-based weight loss programs are acceptable alternatives if participation is in conjunction with the supervision of a physician, physician’s assistant, nurse practitioner/advanced practice nurse or registered dietician.

  AND

  • The patient must be evaluated preoperatively by an eligible licensed Mental Health Professional to ensure the absence of significant psychopathology that would hinder the ability of an individual to understand the procedure and comply with medical/surgical recommendations. The Mental Health Professional must meet the Minnesota Department of Human Services qualifications, as set forth in Minn.Stat. §245.462, subd. 18 (2015). Providers outside Minnesota must be appropriately licensed according to applicable state law.

  AND

  • The physician requesting authorization for the surgery must confirm that the patient's treatment plan includes a surgical preparatory program addressing all the following components in order to improve outcomes related to the surgery and to establish the patient's ability to comply with post­-operative medical care and dietary restrictions:
    • Pre-­operative and post­-operative dietary plan; AND
    • Behavior modification strategies; AND
    • Counseling and instruction on exercise and increased physical activity; AND
    • Ongoing support for lifestyle changes necessary to make and maintain appropriate choices that will reduce health risk factors and improve overall health.

[Hhs1078 3]

Thank you for the responses!

It looks like I will not be getting good approved...period. I don't have any of those comorbidities despite the BMI. sleep study isn't until May. I guess I haven't had a liver panel done though.

It so stinks that the diet has to be within the year, because the one I did was exactly what I need to do (and will have to pay out of pocket for again). At the time Bariatric surgery wasnt even on my radar. But none of that really matters because apparently I am too "healthy" per BCBS standards (which really I AM thankful for), and my BMI is not quite 40...a measly 9lbs from being 40.

I will find out the details Monday.

The frustrating thing for me is I CAN lose weight. I just can't maintain it.....ever.

[LeaninLanc 83]

Don't count yourself out yet. The physicians office is most likely familiar with charting and medical record evaluation that will substantiate your need. Let us know how it goes.