Bad News

   Well, I just heard from my surgeons office--it seems the insurance company says I haven't made all of their qualifications to have to have the surgery. They are saying I haven't met their 6 month doctor supervised diet requirement. I've had 6 consecutive months and he noted my weight each time but didn't write I was dieting and exercising in his notes. Now they are saying I have to do another 6 months of dieting. My PCP is really upset and offered to send in amended notes on my office visits but the insurance company said--no dice !!! I have multiple health problems that would be lessened or even done away with with this surgery and I can't understand why the insurance company would rather spend money ( prescriptions and treatments) time after time treating these problems but won't ok a procedure that would actually save them money in the long run. And truth be told, I was so into getting this surgery--did research, following all of the pre-surgery suggestions by the surgeon ( eating with a baby spoon, not drinking at meals, incorporating more exercise into my daily habits, ect--I REALLY don't think I can get myself psyched up for this surgery again !! Any suggestions?????

I am so sorry that this happen and yes it SUCKS!!!!  Don't reach through the computer screen to slap me but everything happens for a reason.  Good Luck and I know you can do it!! 

You can appeal.  I know it seems like they have a lot of stupid hoops to jump through but it is necessary to meet all their requirements.  I suggest asking the insurance company exactly what kind of documentation they need, and then making sure the PCP does that.

I'm sure you're really mad and disappointed, I know I would be.  This can just be a detour in your road, though, not the end of the journey.

I wouldn't DREAM of slapping anyone  reaching out to me--LOL ( Might utter bad things under my breath maybe !!). Thanks Mallory for the reply--I've been trying to tell myself that same thing all morning--it's something I'll have to keep foremost in my mind I guess.

Kaiser has been really strict with us about doing our food journals every week and turning them in during our 12 weeks of classes, so I know what you mean. I know there are many people in my class that aren't doing them at all and they are in for a real big surprise soon! I would suggest trying to appeal, too. Good luck with everything and I hope it all works out for you!

Thanks Kelley, My PCP offered to send in amended notes of my office visits but the insurance company said they wouldn't accept that--my doctor feels really bad about that--I'll ask the surgeons office how we go about appealing this.

 I have wondered if some doctors get faster approval than others.  Sometimes it comes down to details and if you have jumped through all the hoops but still turned down, it may be how the doctor handled it.   Did you ask your doctor specific questions about why they said no.  I would start there and then maybe check out some different doctors.  I always reccommend a University bariatrics department.  They need patients and seem to help move things along.  The teachers have their own clincs so it doesn't mean that a student will be doing the surgery.  Hope this will help.

I know that another 6 months seems like a lifetime (if appeals don't work).  But just keep thinking that the result is sooooo worth it.  And, in a lifetime, 6 months is not a huge period of time.  I know this is all polyanna talk, but I'm trying to help keep you focused.  Your decision 6 months ago will be as right as it will be 6 months from now.  DON'T let them keep you from you what you know is right for you.  Please....

   When I first started the process for WLS. I called my insurance company and asked them if I could do my 6 months with my PCP. They said that would be fine as long as he documented the information. While I was doing that I went to my surgeon's pre op meeting and signed up, paid my fees, etc. After my six months of diet and exercise were up my PCP faxed everything to my insurance. Apparently my insurance company had changed some rules that took effect in January to the effect that all diet and nutrition classes had to be done through the surgeons office along with a nut. This is something that I did not find out until my six months were up. So I had to do another six months with surgeons office. But I stuck it out and am now 10 weeks post op.

Trust me it will be worth your time to just do whatever they want you too. Their rules might have changed at the beginning of the year too.

Stay in touch with the insurance company personally to keep yourself updated.

Good Luck

Pam

My surgeon's dietician gave me a list of what the progress notes from my PCP had to contain to satisfy the insurance companies. It was very specific.

There is a rule with medical records: If it was not documented, it was not done.