6 month supervised diet help needed... - ThinnerTimes - Gastric Bypass Forum, Lap Band Forum, and Vertical Sleeve Gastrectomy Forum

dutchgirl · 03-10-2006, 12:07 AM

I posted yesterday that I was denied a bariatric surgeon consult because I needed to complete a 6 month supervised diet with a physician.

First off, I was wondering if they can deny the consult because of this. I know they can deny it for the surgery, but I'm not sure about the consult. Anyone who had any experience appealing this would be helpful..

Secondly, did anyone who had done the required 6 month med. supv. diet have any problems getting approved once completed.

Thirdly, is there anything during this process I should be aware of? My PCP was surprised I wasn't approved for the consult and feels I should have the surgery. He is really making sure everything is documented, I.E. my hypertension, back pain, depression, acid reflux, etc.... If there is anything else anyone thinks is important to the documentation?

Also, I have Health Net and when I called about the criteria to meet for surgery, besides the 6 month diet and the BMI, it stated that the patient must have been obese for 5 years. Has anyone had this be an issue? I mean I'll have only been seeing this doctor for 6 months. Does the doctor just need to document that I have said how long I have been obese?

Please, please, please any help or information would be appreciated and would also help me to keep my focus off how devastated I am about how I now have to wait another 6 months...I am just so depressed about having to go through another summer this way...

Cinerbelle · 03-10-2006, 03:46 PM

Hi Sandy,

Before my medical group would give me the referral to see the surgeon I had to complete the below steps (in order):

6 mth supervised diet
Endocrinologist (to rule out Thyroid problems)
Psych Eval
Cardiologist
Pulmonologist

My insurance also required the 5 years proof of obesity, the BMI and many other specificatons. Just follow each step and eventually you will make it to surgery. I know it is time consuming and very daunting, but if the surgery is what you want you will have to play by the medical group and insurances rules. It took me 8 months to get my surgery and I had no problems getting the approval after I had jumped through all their hoops.

Good Luck

dutchgirl · 03-10-2006, 05:08 PM

Hi Cindy;
Thanks for your reply! I had opened an appeal to my insurance company regarding the denial for the consult and my husband just spoke to my appeals rep and she said that the med grp should not be able to deny the consult on the basis of criteria for surgery. It's just a consult for an opinion about the surgery. She told me that she thinks it'll be overturned.

I have requested the Health Plans written criteria for the surgery so that I know what to expect and will do what they require.

How did you prove the 5 year history of obesity? Do you have to have been "morbidly obese" for the 5 years? I have only been 40 BMI for two years and was pregnant for 9 months of that time. Before that I was definately 35 BMI for the 3 years before that. I guess I'll have to get records, but I have changed insurances and doctors more than a few times, so that should be interesting. I also don't recall getting weighed on a regular basis in any of the doctors offices. I do have some Weight Watchers booklets from a couple of years,but they show only a few visits on each. Adding that might help, I'm not sure.

I am glad to hear that once the requirements are met that the surgery does get approved.

Thanks!

I really appreciate knowing that

lealphachienne · 03-10-2006, 06:00 PM

It takes some legwork on your end...call up each previous doctor to get copies of the records sent directly to you. Once you get them, make a copy for your current PCP. Some offices may charge $25 for your records.

With HMO, pretty much if they approve the consult, then they approve the surgery. The consult is the hardest to get. You have to keep working at it...also....see your doctor every month to get weighed. Have her write notes about your diet and medications prescribed and the results of your efforts. That generally will count as a 6 month medically supervised diet.

I had to go through it all too...it took me 10 months. My BMI hovered around 35-38 for many years before I developed major health problems and evenutally got up to BMI 41 just beofre the surgery. It is possible...keep plugging away.

dutchgirl · 03-10-2006, 11:19 PM

Thanks Marie

I think I'm going to call the surgeon and ask how the 5 year history of obesity needs to be and then request the records.

I appreciate the replies and am glad to see that once the criteria is met that people are getting approved. I just need to focus on this process one step at a time and give the rest to God.

Thank you all for your suggestions. I'im glad to have this forum to get information and kind support!

Sweetgirlinsd · 03-11-2006, 08:58 AM

I have health net also.. but i wanted to go to Callery first but my insurance says hes not even the providing doc so i would pay like 20% of surgery plus hosp costs so i couldnt do that.. they told me what surgeon they covered so i researched her and everything. actually a great doc. shes the first woman to do lap gastric bypass. anyways.. my sis and my mom both had surgery by callery so they kinda told me the heads up about stuff for the insurance. so i started my 6 month diet before i really contacted surgeons. i just did the diabetic low cal diet i think its called. my doc approved for me to do so i just went in every month (PCP) to get weighed and stuff. no biggie just time consuming. and for dr. c they required paperwork and doc. for everything.. Dr. ellner (my surgeon now) didnt require anything. Just a list of diets ive tried and all. i got approved in 5 days. for the 5 years of being obese? i guess ive have been.. but they didnt ask. they just looked at family history of being obese. anyways good luck.

riotgrrl · 03-11-2006, 11:32 AM

for the 5 year proof they want some kind of medical record from 5 years ago. i was able to get hospital records from 2001 to satisfy my insurance companies requirements.

whatever you get must have a date and also a weight listed on it.
good luck!

Duckie · 03-11-2006, 01:54 PM

What a run around! GOod luck hon. Keep us posted on your efforts.