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I had to do 6 months of supervised program, but it was NOT required by my insurance company. I have Anthem BCBS of CA., but I live in Maryland and surgeons have to follow BCBS requirements for pre-authorization in said state, and Maryland requires 6 months documented diet within the past 2 years (2, consecutive 3 months or 6 consecutive months). Before finding out about the state requirement, I actually posted about the 6 months requirement when I first started out and one member suggested I could file a grievance, here’s part of the response: Second, if it is your insurance, find out whether your insurance policy is fully funded, and if it was "issued, amended, delivered or renewed" in CA. If so, your plan should be covered by the DMHC rules. You can file a grievance with the DMHC and they will order the insurer to waive the requirement. http://www.dmhc.ca.gov/aboutTheDMHC/org/boards/cap/Bariatric REV.pdf
See also http://www.asmbs.org/Newsite07/resources/ASMBS%20Position%20 Statement%20on%20Preoperative%20Supervised%20Weight%20Loss%2 0Requirements.pdf
Good luck. I also have BCBS fep and trying to get approve. I think the new requirements this year is stupid. Hope everything goes well for you!
You could call the Human Resource department of your employer and find out if it is covered or not. I would also call the insurance company and ask for a copy of the bariatric surgery requirements. for example, I have Aetna. It is their clinical bulletin 0157. I printed a copy of that and went through it with a fine tooth comb to make sure I met all the requirements.
Good Luck to you!
Nan
HW 300 / SW 280 / CW 138 / GW 140
Hit Goal 4/2/2010
Good Luck!!
Nan
HW 300 / SW 280 / CW 138 / GW 140
Hit Goal 4/2/2010
Based on the reason you were denied, it sounds like your insurance requires a 6 month physician supervised diet (as do MOST insurances). This means you have to start with your physician and go 6 consecutive months (not missing one month or they will deny!). It entrails weighing in, tracking BMI, followoing a reduced calorie diet, etc.....they want to see an attempted weight loss for 6 months, documented in the office notes of your pcp.
Did you do that in the past 2 years? If you did, you can appeal by proving you have done that by providing copies of the office notes from your pcp. If you did not do that yet, you need to complete the 6 month supervised diet, then resubmit for approval. There's no getting around it if your insurnace co requires it.
Good luck to you!
Nan
HW 300 / SW 280 / CW 138 / GW 140
Hit Goal 4/2/2010
on 5/18/11 11:06 am - Bowie, MD
Thank you

