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I don't know about your insurance, But the best way to know is to call them or check their requirements online.
My insurance would take 6 months supervised diet I did with the past 2 years.
GoodLuck
After I posted this in a panic, I realized that I had seen a specialist within the past two years who I figured probably did document my weight. It wasn't for anything major and I had really forgotten about it since no treatment was necessary. I called their office and they do have my weight documented on the 2 visits--and even included the dreaded words "morbidly obese". That should do it, I think, in addition to my new PCP that I began seeing earlier this year. Since I won't be eligble for surgery until January/February 2012, the ins person at the doc's office said I only need documentation from 2010 and 2011, so I think I've got it covered.
I'm so nervous about possibly being denied. I haven't done any official type diets since 2003--and at that time I lost 105 lbs. on weigh****chers (took me no time to gain it back). The insurance person thinks that was too long ago for the insurance to consider it a real effort. It's not like I haven't tried to lose weight since then, I just haven't spent money on it. Anyway, we'll see what happens. She seems to think it'll be okay to say that I've tried dieting on my own.
I worry about everything! It's my thing. Thanks, again, for responding. Sorry for writing you a book in response!
EDITED: change feb 2013 to 2012, duh.
HW: 272 lbs. (BMI 49.7) SW: 237 lbs. (BMI 43.3) GW: 140 lbs. (BMI 25.6)
I had surgery in 2009 and all three of my children had surgery in 2010. We all are covered under my insurance which is Aetna so I know the approval process pretty well. Three of us did the 3 month multidisciplinary program and my one son did the 6 month supervised.
Two of us were denied at first and had to appeal before getting approved and my two sons were approved right away.
I can tell you from experience you will need to show a 2 year history or they will deny. I can totally relate to avoiding the doctor when you are overweight - I did the same thing. Do you have a recorded weight ANYWHERE?? Weigh****chers records, ER, urgent care, anywhere that may have weighed you in that time frame. It doesn't have to be from your doctor. I was missing a year, but had documentation (weigh****chers attendance card) that showed my weight. My son also was missing a year but he had been to urgent care in that year so we called them and got a copy of that office visit to submit because it had his weight on.
Worst case scenerio, and it is not what you are going to want to hear, is you will have to wait until Aug 2013 so you will be able to show your 2 year history.
You can try to submit and see what happens, and try an appeal. I have appeal letters from myself and my physician if you get yourself in that spot and need samples.....
Good Luck to you!!
Nan
Nan
HW 300 / SW 280 / CW 138 / GW 140
Hit Goal 4/2/2010
Hello all,
I had WLS 2007 and lost a total of 125 with gastric partitioning. The write up from the doctor :
Is a 48-year-old female who has lost a total of 125 pounds with gastric partitioning. The patient has now had this three years and has lost all this weight and is stable'. She is now complaining of excess skin of her lower abdomen, legs and buttocks. Due to the extreme weight loss, she has lost her skin integrity and now has excessive skin folds of her abdomen and thighs and buttock area. I do not feel any further weight loss or conservative therapy will be of any benefit.
I am now recommending a lower body lift with medial thigh lift which can be done in two different stages. I do not feel any other therapy would be of benefit. Therefore, if this could be approved, it could be done as an outpatient..
The write up had no medical terms as in:Hypertrophic skin condition, intertrigo with candidiasis.
The doctor submitted these code: ICD 9:278.1 and CPT: 15830,15832-50,15865
Tricare disapproved the request saying "its not covered" and they (Tricare) called it Factual.
I was wondering if anybody had any luck in the appeal process and / or are there different codes that can used to do the same surgery...tummy tuck etc.......what about the ICD Code?? I have no idea...but I do know they have done this procedures before.
Any and all information will be greatly appreciated....willing to travel to a Tricare Doctor who can get these approved!!
Ciao~
Brad
BTW the write is for my wife...not me.....:)
Anyone out there get the VSG through health-net medi-cal?? If so what were their specific requirements? How long did it take to get the approval you needed? I fit all criteria for WLS (BMI of 46,high cholesterol,high trigycerides,early onset diabetes,possible sleep apnea-getting sleep study next week) except I have no documented diets from the dr. But I have dieted numerous times throughout the yrs. The weight always comes back. I have researched all WLS options and feel that I need the VSG bc Ibuprofen is th only thing that takes my pain away for ANYTHING and I really don't want to have problems down the road with taking it after the rny and no way in heck is anyone putting any type of band on my stomach,too many horror stories for all that...lol. Anyway,some insight would be awesome! Thanks!
I will send you a friend request and we could chat
Hockeymom87 · 0 replies · 731 views
