Weight loss insurance requirement

[Deedee1987 0]

Hello forgive me if this issue has been asked plenty of times alreasy i just have a concern...

so next week is my 6th month appt for the med supervised diet i am required to do for insurance. I am required to lose 29lbs before i am cleared for surgery. I have been cleared for everything else. I i have lost only 10lbs which has been a horrible struggle since i began. My question is will the paperwork be sent in anyway with my documentation that i attempted to lose this much? Or will i be forced to continue until i lose the rest? I have meridian medicaid, 290lbs, have high bp, diabetes, and sleep apnea. I am becoming exhusted and am ready to give up again. What will happen now that its been 6 month and only a 10 lb loss?

Edited June 25, 2018 by Deedee1987

[RickM 1,750]

The first thing to do is to verify whether this loss requirement is that of the insurance company, or of the surgeon's program. Six month diets are fairly common for insurance companies to require, though the specific loss requirement is less common - that is more typical of some surgical programs, irrespective insurance requirements.

Check with your insurance company - call them or find their policy bulletin on their website, which will spell out the specifics of their requirements. If indeed it is an insurance requirement, you might have to continue, or the requirement may be negotiated or appealed - your surgeon's insurance coordinator can help with that. If it is a requirement of your surgeon's practice, that can also be negotiated as this is not a standard requirement within the industry (you can go to another practice that doesn't have such requirements).

In either event, talk to your surgeon's team - including whatever dieticians or therapists they may have on staff or referral to see if you can get to the root of the problem. Some programs may just reject you for "not trying" or being "non-compliant" while others will help craft a solution to your problem. You may have a greater than average metabolic problem that is inhibiting your weight loss, and this may point to the need for a stronger surgery than the bypass or sleeve - the DS is a stronger metabolic tool than the others and may be worth looking into, though your doc's practice may not offer it. It's better to investigate it now and understand it than get into a bypass that may not be strong enough and have to revise to it later - that's a real complicated revision that few can perform.

Good luck in working this out....

[anonbaribabe 236]

My insurance also requires that I lose a certain amount of weight before I am cleared (5% of my starting weight). The coordinator that I'm working with told me that if I don't lose the 5% in the specified amount of time that I can weigh in every couple of weeks until I meet my goal. If I don't meet my goal in that amount of time, it doesn't disqualify me—I just have to wait until I hit the 5% to continue. I agree with Rick that you should confirm if it is a requirement of your insurance company or the surgical center in order to determine how to move forward and what options you have. Hope that everything goes well!

[AshMarie794 164]

I totally feel your stress and anxiety about the whole insurance process. I know I posted my story a few months back but I completed my 6 month pre op and am currently DOING IT AGAIN! I originally did my 6 month with my family doctor but because of how she worded my paperwork my insurance denied me the first time. My surgeon did everything he could and even called the insurance company to do a peer to peer with the doc that oversees the cases. NOPE! I was set for surgery and it was denied 2 days before!!!! So I was already doing my pre-op diet, had my Vitamins and felt prepared. My new surgery date is now August 29th and I can not for the life of me let myself get prepared. Its feels like a mental road block. I haven't thought about surgery or anything to do with it other than going to my appointment. And for the most part my calendar reminders pop up and that is how I know when my next apt is. I just can not bring myself to think about the surgery or what I should be doing.

[Lioness815 44]

On 6/28/2018 at 1:08 PM, AshMarie794 said:

I totally feel your stress and anxiety about the whole insurance process. I know I posted my story a few months back but I completed my 6 month pre op and am currently DOING IT AGAIN! I originally did my 6 month with my family doctor but because of how she worded my paperwork my insurance denied me the first time. My surgeon did everything he could and even called the insurance company to do a peer to peer with the doc that oversees the cases. NOPE! I was set for surgery and it was denied 2 days before!!!! So I was already doing my pre-op diet, had my Vitamins and felt prepared. My new surgery date is now August 29th and I can not for the life of me let myself get prepared. Its feels like a mental road block. I haven't thought about surgery or anything to do with it other than going to my appointment. And for the most part my calendar reminders pop up and that is how I know when my next apt is. I just can not bring myself to think about the surgery or what I should be doing.

That sucks. Don’t stress over why you can’t control ...But don’t get discouraged to the point that you don’t prepare for this change. It will happen and you will do yourself a disservice to not have your head in the game. Good luck!