Jump to content
×
Are you looking for the BariatricPal Store? Go now!

Caresource Ohio requirements



Recommended Posts

For anyone who has Caresource in Ohio, here is their policy as it pertains to Bariatric Surgery as of July 2016:

A. SUBJECT
Obesity Surgery
B. BACKGROUND
Surgery for morbid obesity, bariatric surgery, and gastric bypass surgery is a major surgical procedure with significant risk of surgical and post-op complications that should be considered medically necessary only as a treatment alternative when a concerted effort a conventional and conservative management has failed for those who meet the policy criteria below. Prior authorization request for Morbid Obesity Surgery and supporting information must be submitted by the surgeon intending to perform the procedure. Further supporting information may be presented by the PCP or other practitioners, but unless the prior authorization request is submitted by the attending surgeon, the request will be administratively denied for lack of information.
C. DEFINITIONS
N/A
D. POLICY
I.
The surgery should be considered medically necessary if ALL of the following conditions are met:
A. The patient is at least 21 years of age. Members less than 19 years old will be
considered only under extreme circumstances.
B. The BMI (Body Mass Index) and associated conditions suggest surgery is the most prudent treatment:
1. BMI > 50 with or without associated co-morbidities and failed conservative weight loss
attempts as per 3B
2. BMI 40-50 with 1 or more significant co-morbidities not well controlled with appropriate treatment that a surgical weight loss treatment is likely to improve
3. BMI 35-40 with 2 or more co-morbid conditions that are not well controlled with appropriate treatment that a surgical weight loss treatment is likely to improve:
a. The co-morbid condition is either poorly controlled on appropriate medical therapy and would likely improve with weight reduction OR by virtue of family history and existing clinical conditions, the patient would remain high risk for short term co-morbid complications without the surgery
Examples include
  • Poorly controlled hypertension on multi-drug therapy
  • Inadequately controlled diabetes despite high does insulin treatment and other therapeutic regimens
  • Lipid disorder on maximum drug therapy and lifestyle modification without control
C. Written clinical documentation and supporting information from the attending surgeon
must include:
1. Letter of medical necessity
2. Evidence that there has been at least a 9 month documented physician supervised trial of diet and exercise within the last 24 months (adapted from NIH recommendations)
3. Summary of co-morbid conditions
4. A description of a multi-disciplinary approach to preparing and managing the patient in the pre-operative and peri-operative periods and through an extended post-operative period
5. Evidence the patient has been evaluated from a psychological standpoint within the past 6 months and which supports that the patient does not have an underlying psychiatric condition which would interfere with the success of the surgery and that the patient will withstand the rigors of the surgery and maintain long-term follow-up care. If the member is under psychiatric care, documentation from their current treating psychiatrist is also required
6. Supporting letter of medical necessity from the patient’s PCP, recommending the surgery and documenting that the patient has undergone medical evaluation to rule out other treatable causes of obesity
D. Patients with a history of non-compliance with medical care and any psychiatric illnesses that may hinder compliance with the post-operative regimen are not suitable for surgery.
--
Your surgeon may also require additional testing and clearances, but this is what Caresource requires. Hopefully this helps someone.

Share this post


Link to post
Share on other sites

Thank you for this information. I'm just getting started trying to work with them for a possible revision to a duodenal switch. I saw my primary care doctor today and told her I needed a 9 month physician documented diet and she asked me if she needed to fill out a form and what other info was needed. I told her I'd call Caresource to find out.

I called and got a seriously unhelpful rep who said she can't tell me, that the doctor needs to call Provider Services. I told her that this makes me nervous. If I don't have the info myself, how am I to know what's being done is correct? My doc's office could get the wrong info and 9 months from now we submit it for approval only to be told "The 9 month diet wasn't done correctly." It will be ME who has to wait another 9 months. The rep was unmoved. She kept saying she couldn't help me.

Frustrating!

Share this post


Link to post
Share on other sites

I will add that the surgeon's office specified in their paperwork that the notes from the Primary Care Doctor must include that they counseled you on both diet and exercise, not just weight checks.

Share this post


Link to post
Share on other sites

I have 5 weeks left of my 9 month diet! Its forevrr and half long and frustrating makes ya contemplate all of this, which is what they want! My pcp calls it hazing and i thought he was crazy until lately. I was email a document for my primary to fill out for 6 months of my current/previous weight. Exercise diet etc. Then i am finishing up my last 2 appts with my nut. Your primary also needs to write a letter of recommendation stating why this is beneficial for you. Your co morbidities and how there being treated and 1 forget the last 1. But be on your A game! Make sure yoy have everything. With me i am pre diabetic, and i have insulin resistance with history of obsesity in my family. In pretty much the healthiest fat person ever. In case my co morbidities arent accepted im keeping at my bmi of 50 which has been so tough! In the beginning i dropped to 1200 calories and practically fried myself. Then finding out that only my high bmi can be accepted made me raise the calorie intake and stay at a stable weifht of 258 to 262. Its harder then dropping 20lbs! Good luck ladies! You can pme if you need any other help or advice I've called and research the hell out of caresource!

Sent from my SM-G900P using the BariatricPal App

Share this post


Link to post
Share on other sites

Thanks for the info, I appreciate it.

Hopefully I can get the D/S because I don't really feel the restriction that so many people talk about with the sleeve. I felt it for about 30 days after surgery, but then not again. So I basically have to rely on just weighing my food and stopping when I'm out. I eat between 700 and 900 calories a day and I'm not losing like I should be. Time for me to move past the sleeve.

Share this post


Link to post
Share on other sites

Right i am getting the rny. Because like you said you dont feel the restriction, which its not too much bigger then what i may end up with. But i have read and seen people say they can eat whatever they want. Well that being said im getting this because i ate whatever. So i want that feeling ill get when i attempt to eat something that put me in this place. I know theres moderations and all that but still. . If that all makes sense

Sent from my SM-G900P using the BariatricPal App

Share this post


Link to post
Share on other sites

Ok, so I am basically in my first steps to figure out what's needed to get approved for surgery. I have an appointment Monday with my family doctor. In reading about the 9 month period, I'm getting very nervous! I REALLY don't wanna wait that long! My BMI is right around 50ish right now. I just don't know what to do.......

Share this post


Link to post
Share on other sites

4 hours ago, piano2083 said:

Ok, so I am basically in my first steps to figure out what's needed to get approved for surgery. I have an appointment Monday with my family doctor. In reading about the 9 month period, I'm getting very nervous! I REALLY don't wanna wait that long! My BMI is right around 50ish right now. I just don't know what to do.......

I hate to tell you, but they're pretty strict about their 9 month diet. I'm a revision from a sleeve to a DS so my surgeon's office thought they *might* approve me without the 9 month diet due to me following a diet all along but they turned me down for the diet. The surgeon's office did an appeal and sent them 6 months of a diet and told them my comorbidities and BMI (higher than yours) and they denied the appeal.

Luckily for me I was able to switch to a different provider during open enrollment. ALL the other available plans had a 6 month diet. My surgeon's office sent through my application to the new insurance company on January 12th after only being on their plan for 12 days. We got back an approval by the end of the month.

Good luck to you. Make sure you do every single month with them and be sure your doctor's office charts each one.

Share this post


Link to post
Share on other sites

Ok so I had surgery 12/19/16 and with having Caresource as well! It was literally a full year start to end! The 9 months go by so quickly! This entire journey is very much mental! You will need to be mentally prepared for all this change that will happen! And I'm not sugar coating anything, be prepared to have moment of total mind fucking. (Excusing my language) but it's going to happen! You will have your visit with your pcp your medical dr surgeon psych nutritionist and in between your testing done! You'll be so focused on making sure you lose and not gain that the length of time will be totally not there! Just be patient! It will come in no time! Now I am 9 weeks out tomorrow I'm down 47lbs and I'm happy with everything! I have days of hardships with food and moments of weakness and yes at time I fail but I don't let it bother me! The 9 months of visits will not mean a thing once you have surgery! You'll be like me and encouraging the next person that the wait is worth it!


Share this post


Link to post
Share on other sites

Thanks guys! I appreciate the feedback. I know that it'll go by quick, I'm just one of those people that once I get my mind set to something, I just can't wait. But I am hopeful that I will succeed.

Share this post


Link to post
Share on other sites

Hello everyone!

Such good information here, thank you. I'm in the beginning stages of preparing for my Rny and so many questions have been answered. My question is the 9 month diet. Earlier this year I was prescribed Adipex for 3 months. Could that count as 3 months?

Thanks so much,

Dani

Share this post


Link to post
Share on other sites

Create an account or sign in to comment

You need to be a member in order to leave a comment

Create an account

Sign up for a new account in our community. It's easy!

Register a new account

Sign in

Already have an account? Sign in here.

Sign In Now

  • Trending Products

  • Trending Topics

  • Recent Status Updates

    • Prdgrdma

      So I guess after gastric bypass surgery, I cant eat flock chips because they are fried???  They sell them on here so I thought I could have them. So high in protein and no carbs.  They don't bother me at all.  Help. 
      · 1 reply
      1. NickelChip

        It's possible for a very high fat meal to cause dumping in some (30% or so) gastric bypass patients, although it's more likely to be triggered by high sugar, or by the high fat/high sugar combo (think ice cream, donuts). Dietitians will tell you to never do anything that isn't 100% healthy ever again. Realistically, you should aim for a good balance of protein, carbs, and fat each day. Should you eat fried foods every day? No. Is it possible they will make you sick? Maybe. Is it okay to eat some to see what happens and have them for a treat every now and again? Yes.

    • NovelTee

      I'm not at all hungry on this liquid pre-op diet, but I miss the sensation of chewing. It's been about two weeks––surgery is in two days––and I can't imagine how I'll feel a couple of weeks post-op. Tonight, I randomly stumbled upon a mukbang channel on YouTube, and it was strangely soothing... is it just me, or is this a thing? 
      · 1 reply
      1. NickelChip

        I actually watched cooking shows during my pre-op, like Great British Baking Show. It was a little bizarre, but didn't make me hungry. I think it was also soothing in a way.

    • Clueless_girl

      How do you figure out what your ideal weight should be? I've had a figure in my head for years, but after 3 mths of recovery I'm already almost there. So maybe my goal should be lower?
      · 3 replies
      1. NickelChip

        Well, there is actually a formula for "Ideal Body Weight" and you can use a calculator to figure it out for you. This one also does an adjusted weight for a person who starts out overweight or obese. https://www.mdcalc.com/calc/68/ideal-body-weight-adjusted-body-weight

        I would use that as a starting point, and then just see how you feel as you lose. How you look and feel is more important than a number.

      2. Clueless_girl

        I did find different calculators but I couldn't find any that accounted for body frame. But you're right, it is just a number. It was just disheartening to see that although I lost 60% of my excess weight, it's still not in the "normal/healthy" range..

      3. NickelChip

        I think it's important to remember that the weight charts and BMI ranges were developed a very long time ago and only intended to be applied to people who have never been overweight or obese. Those numbers aren't for us. When you are larger, especially for a long time, your body develops extra bone to support the weight. Your organs get a little bigger to handle the extra mass. Your entire infrastructure increases so you can support and function with the extra weight. That doesn't all go away just because you burn off the excess fat. If you still had a pair of jeans from your skinniest point in life and then lost weight to get to the exact number on the scale you were when those jeans fit you, chances are they would be a little baggy now because you would actually be thinner than you were, even though the scale and the BMI chart disagree. When in doubt, listen to the jeans, not the scale!

    • Aunty Mamo

      Tomorrow marks two weeks since surgery day and while I'm feeling remarkably well and going about just about every normal activity, I did wind up with a surface abscess on on of my incision sights and was put on an antibiotic that made me so impacted that it took me more than two hours to eliminate yesterday and scared the hell out of me. Now there's Miralax in all my beverages that aren't Smooth Move tea. I cannot experience that again. I shouldn't have to take Ativan to go to the lady's. I really looking forward to my body getting with the program again. 
      I'm in day three of the "puree" stage of eating and despite the strange textures, all of the savory flavors seem decadent. 
      I timed this surgery so that I'd be recovering during my spring break. That was a good plan. Today is a state holiday and the final day of break. I feel really strong to return to school tomorrow. 
      · 0 replies
      1. This update has no replies.
    • BeanitoDiego

      Now that I'm in maintenance mode, I'm getting a into a routine for my meals. Every day, I start out with 8-16 ounces of water, and then a proffee, which I have come to look forward to even the night before. My proffees are simply a black coffee with a protein powder added. There are three products that I cycle through: Premier Vanilla, Orgain Vanilla, and Dymatize Vanilla.
      For second breakfast on workdays, I will have a low-fat yogurt with two tablespoons of PBFit and two teaspoons of no sugar added dried cherries. I will have ingested 35-45 grams of protein at this point between the two breakfasts, with 250-285 calories, and about 20 carbs.
      For second breakfast on non-workdays, I will prepare two servings of plain, instant oatmeal with a tablespoon of an olive oil-based spread. This means I will have had 34 grams of protein, 365 calories, and 38 carbs. Non-workdays are when I am being very active with training sessions, so I allow myself more carbohydrate fuel.
      Snacks on any day are always mixed nuts, even when I am travelling. I will have 0.2 cups of a blend that I make myself. It consists of dry roasted peanuts, cashews, pumpkin seeds, sunflower seeds, pistachios, and Brazil nuts. This is 5 grams of protein, 163 calories, and 7 carbs.
      Breakfast and snacks have been the easiest to nail down. Lunch and dinner have more variables, and I prepare enough for leftovers. I concentrate on protein first, and then add vegetables. Typically tempeh, tofu, or Field Roast products with roasted or sautéed vegetables. Today, I will be eating leftovers from last night. Two ounces of tempeh with four ounces of roasted vegetables that consist of red and yellow sweet peppers, sweet potatoes, small purple potatoes, zucchini, and carrots. I will add a tablespoon of olive oil-based spread, break up 3 walnuts to sprinkle of top, and garnish with two tablespoons of grated Parmesan cheese. This particular meal will be 19 grams of protein, 377 calories, and 28 grams of carbs. Bear in mind that I do eat more carbs when I am not working, and I focus on ingesting healthy carbs instead of breads/crackers/chips/crisps.
      It's a helluva journey and I'm thankful to be on it!
       
      · 0 replies
      1. This update has no replies.
  • Recent Topics

  • Hot Products

  • Sign Up For
    Our Newsletter

    Follow us for the latest news
    and special product offers!
  • Together, we have lost...
      lbs

    PatchAid Vitamin Patches

    ×