90 Day Weight Loss Centers (includ. behavior mod and nutritionist)

Hey everyone,

I need to find an affordable weight loss center that offers (or will customize to a) 12 week program. I have sleep apnea and a hernia (that can turn into cancer if I don't lose weight) however Aetna refuses to budge until I do this 90 day program. Of course, they don't want to pay for it either. I'm 450 lbs.

Ok. That's enough about me.

I live in Downey, CA and I am having a hard time finding such a program near my location. Does anyone know a place I should be checking out, etc? The program HAS to include behavior modification and a nutritionist.

I'm pulling my hair out. I appreciate any and all help!

Thanks

Hi there,
I live in Norwalk, CA your neighbor, and I went to a 90 day program through my medical group.  It was through Bright Medical Group in Whittier and it was with a nutritionist and included behavior mgmt.  I don't know if they take Aetna or not but it's worth a try.  It is now called PIH Bright Medical, it's on Whittier Blvd  and Santa Gertrudes.
Good luck on finding someone, I hope this helps.  Don't give up, keep trying.  You could also call my surgeons office maybe they could recommend someone.  That # is: (714) 996-2009.  Take care and God Bless.                  Hugs,  Donna

In the state of CA you do not have to do the medically supervised diet. The supervised diet is just a hoop and stall tactic that IPA and insurance use to delay or prolong patients getting WLS. If you've already received your denial letter then appeal directly to your insurance now. They have 30 days to respond to your appeal. If they do not give you an answer to your appeal within the 30 days then on the 31st day call up the CA Dept. of Managed Health Care (DMHC) http://www.dmhc.ca.gov/ and file a grievance with them based on not getting the referral because of the 90 day program. If your insurance denies you  based on this criteria call up the DMHC and file a grievance when you receive that denial letter. The DMHC has a peer review on this very subject. Here is the link: include this in your appeal letter
http://www.dmhc.ca.gov/aboutTheDMHC/org/boards/cap/Bariatric REV.pdf

SUMMARY CONCLUSION There is no literature presented by any authority that mandated weight loss, once a patient has been identified as a candidate for bariatric surgery, is indicated. There is a mixture of results that question whether weight or truncal obesity is a risk factor for complications after bariatric surgery. The more analytic studies have not found that body mass index (BMI) or total weight is an independent risk factor for complications or death from bariatric surgery. 
No institution that has recently published data on bariatric surgery describes a protocol requiring weight loss between identification of the need for surgery and the surgery. Many institutions in California have published results of surgery with particular focus on factors that contribute to morbidity and mortality. No paper from a California institution mentions mandated weight loss before bariatric surgery. Nor does any literature regarding the treatment for the morbidly obese recommend continued weight loss during the period between identification of the need forbariatric surgery and the surgery. 
Mandated weight loss prior to indicated bariatric surgery is without evidence-based support.  Mandated weight loss prior to indicated bariatric surgery leaves the patient at increased risk from the patient’s comorbidities. Mandated weight loss prior to indicated bariatric surgery is not medically necessary. Mandated weight loss prior to indicated bariatric surgery would be deviant from the standard of care practiced in the United States and other published countries. The risks of delaying bariatric surgery, while not entirely known in the short-term, are real and can be measured. Any potential value of losing weight prior to bariatric surgery is theoretical and not supported by any data. An experimental study including fully informed consent to determine if there were a reduction in risks or other benefit from mandated weight loss prior to bariatric surgery is indicated. 
IMR Decisions from the DMHC:
Ref ID #MN07-7341
Reviewer's Findings:
A 45-year-old female has requested gastric bypass surgery without first completing the Medical Group’s six-month supervised dietary counseling program for treatment of morbid obesity. Findings: The physician reviewer found that this patient clearly meets the criteria set by the National Institutes of Health for surgical treatment of obesity with a high BMI and co-morbidities that will likely be ameliorated or eliminated by bariatric surgery. With regard to the preoperative dietary counseling program, there is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the morbidly obese. In fact, the Swedish obesity study identified that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for these patients. In addition, recent studies indicate that bariatric surgery is associated with decreased over all mortality for the morbidly obese. The psychological evaluation indicates the patient is an appropriate candidate for the gastric bypass procedure.
http://wp.dmhc.ca.gov/imr/detail.asp?id=7341&optFormat=html& cboDetermination=Overturned+Decision+of+Health+Plan&cmdSearc h=Search&cboMC=Morbid+Obesity&cboTreatment2=0&cboDiagnosis2= 0&cboDT=0&cboType=0&txtDetails=supervised+diet


Ref ID #:MN05-4907
Reviewer's Findings:
The patient is a 58-year-old female who is 64 inches tall, weighing 321 pounds with a body mass index (BMI) of 55.1. She is requesting authorization for gastric bypass surgery. The patient has hepatitis C and other significant comorbid conditions. The patient outlines a significant history of family obesity and attempted weight loss both through supervised and unsupervised diet plans. The patient completed a psychological evaluation and it was recommended that she see a therapist both before and after gastric bypass surgery. With a BMI of 55.1 and comorbid conditions, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that gastric bypass surgery will be beneficial for this patient. Furthermore, the patient does not require further dietary workup prior to undergoing weight loss surgery. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the obese. Moreover, regarding the patient’s psychological status, the NIH recommends psychological screening for those with eating disorders. This patient has completed a psychological evaluation, which found her in good mental health, well informed about the proposed surgery, and in a stable living situation. The patient should follow through on the recommendation to see a therapist both before and after bypass surgery. Based upon the information set forth above, I have determined the requested surgery is medically necessary for treatment of the patient’s medical condition. The Health Plan’s denial should be overturned.
http://wp.dmhc.ca.gov/imr/detail.asp?id=4907&optFormat=html& cboDetermination=Overturned+Decision+of+Health+Plan&cmdSearc h=Search&cboMC=Morbid+Obesity&cboTreatment2=0&cboDiagnosis2= 0&cboDT=0&cboType=0&txtDetails=supervised+diet

Thanks for the information! I'm still sort of confused on how to exactly proceed. Maybe you can help me out.

Here is what has been done so far:

1) Initial request was denied based on lack of 6 month supervised diet or 90 day 3 tier program (exercise, dietician, behavior modficication).

2) The insurance workers at my surgeons office scheduled a peer-to-peer with my surgeon and  the insurance companies medical advisor. This was denied a week later due to the lack of 6 month supervised diet or 90 day program.


I have only been given a letter of denial from the first request. How do you think I should proceed from here on out?

Thanks again for all your help!

 You have a HMO right? I think that you have to appeal to Aetna first before you can file a grievance with the DMHC. You have to give Aetna a chance to reconsider their denial. If they deny you again then contact the DMHC and file a grievance. Usually it doesn't get to this point. If you appeal and include the peer review that I gave you above, most insurance companies will overturn their denial.  

Things to include in your appeal:
you meet NIH criteria for WLS (BMI > 35 with comorbids or BMI > 40 without) 
you have tried and failed multiple diets (list all that you remember)
list your comorbids
include a letter of recommendation from your surgeon/ any medical doctors you can
copy of the denial letter from Aetna
and of course the peer review from the DMHC
make sure you send it certified mail or if you can file the appeal online. I did my appeal  over the phone, if you go this route make sure that you keep notes and document everything.

Here is a thread by someone in your situation but with a different insurance.  http://www.obesityhelp.com/forums/amos/3866637/Denied-a-refe rral-for-not-having-6-mo-phys-doc-diet/#31043820 If you are in CA and have a HMO you will  most likely have the same outcome. I don't know why surgeon's offices don't know about this peer review. Some of them still require patients to lose 10% of their weight before they'll agree to surgery, again that's not required, per the DMHC peer review. I guess they have so much to keep up with with all the different insurance criteria. Why not bring the peer review in to your surgeon and maybe it will help someone who comes after you.


Edited to add the link to the thread

Thanks!