Need some feedback

Hello all. This is a report from another forum. I appolgies for the double post, however I put this thread in the wrong forum. Moderators please feel free to delete my other post. I want to make sure I am not missing anything as I get ready to see if my insurance will cover my RNY. I have BC/BS of Alabama, PPO. Please follow what I list out below as these all will be presented to my insurance as to receive coverage for my RNY. Please give both positive and negative feedback. If you see something felt I am doing wrong or something I am missing, please let me know. Thanks!!! I am 6-2.5 346# w/ BMI of 43.9. I have just come from my 2nd visit with my PCP following the needed 6 month DR supervised weight loss attempt. I have lost another 5lbs. (down 11lbs since starting). I am using Nutrisystem as my diet method, saving all receipts for my insurance. In may 2006 I was diagnosed with Severe Sleep Apnea. (Man, what a diference a good night o sleep can make on your psychie). My sleep Dr. wrote a letter for me stating ... "I had 127 events with an O2 saturation low of 80.9% durring the irst 30 minutes of testing alone which required them to follow emergeny protocol by placing me on a Cpap machine. I was prescribed a Cpap and currently use it. I have receipts also to show proof o purchase of my Cpap as well. My insurance requires a documented medical history of obesity for 3 years. I can show a BMI of 39.5 or higher for the past 5 years. I am going to see an orthopedic specialist next week to discuss the Knee and ankle pains (and popping and clicking) that I have. I am going to ask him for a letter that will show support of WLS needed to help my joints long term. I also have proof through receipts that I was a paying member of 2 gyms for 3 out of the last 5 years, and I will get a letter from my leasing agent that shows a health club is included where I currently live. My PCP is completely behind my journey, and will support it with a letter stating that WLS is medically needed. He has also started me on (with rx script) Nexium for constant Reflux/Gerd. (Just no upper GI was done). This will also be included in my medical records. My mother has this surgery, she did have some complications but all in all she did very well. THis is a great tool that we can utilize. However I will only be able to utilize this tool if my insurance company approves me. I am ready and willing to hire an advocate/Esq to handle my appeals if I get denied however. Any thoughts?

Hi Chris: I have BCBS of AL and had surgery in October, 2006.  I will tell you what I did to get approved.  First of all, you must make sure that whatever diet you are on (I did WW), must be supervised by your PCP.  That means you must see your PCP monthly (consecutively and not skipping ANY visits) for 7 months....I know its a 6 month supervised diet, but they consider the first visit to be a consult and so you must actually have 7 visits before submitting for approval.  Your PCP must also document your weight and your diet and exercise program at each visit.  It cannot just be a weigh in..you must have an actual MD visit and there must be a progress note generated at each visit.  I took it upon myself to see a nutritionist also...just for extra back-up...not every month but about 3-4 times during the 7 month period.  This is important because they do not just want a letter from your PCP suggesting you have surgery...they will require a copy of the actual medical record to verify that you saw your PCP monthly and progress notes were written.  What I did is after the supervised diet period was over I asked my PCP to write a comprehensive note indicating that I had followed the diet and exercise program appropriately and had some results but that she felt that bariatric surgery was the only option to alleviate my co-morbidities. I still had a couple of tests that had not been completed at the end of the supervised diet so that delayed things for about another month...I still continued with the diet and I went to my PCP another time to make sure I didn't let a month lapse without a visit (just in case I wasn't approved, I didn't want to have to start over for another 7 months!).  When everything had been completed, I requested a copy of my chart from my PCP.  I scanned that copy of my record into my computer just so I would always have it and could e-mail it to anyone at any time.  (Many companies will play the we don't have the records game a million times and I just wanted to be able to say I would send it right away - I didn't have any of that foolishness from BCBS though).  I then gave a complete copy of my PCP's record to my surgeon and then submitted it along with my chart from the surgeon's office to BCBS all at once. Once it was submitted, I was actually approved within 12 days.  I had no problems with them...I'm thinking because they had no reason to deny me based on the records submitted.  If you comply with their guidelines, I don't think they will deny you.  I see that you used Nutrisystem (they won't care about the receipts though), which is fine, as long as you saw your PCP monthly without fail and that PCP wrote a note at each visit.  They are pretty serious about the supervised diet, so just make sure that everything is up to par with that and I don't think you should have any problems.  Feel free to PM me if you need any more info and good luck with everything.