reachbree

LOL!! Thanks 2gg So true, the policy wording is so important!

That's great Congrats!!!! Question-What types of backup documentation did your Dr submit with the authorization? I am working on gathering some things that i think may help..not much but for instance I printed out my 24 hr Fitness gym visits in 2011 (only year i had constant visits but in 2012 I had a 20lbs weight loss following all of those gym visits!... So i printed my Dr.s weight charts from 2011-current and put notes wherever my weight increased, or decreased. Do you think this is necessary? I've never had a supervised Weightloss plan (not even weight watchers) until now (supervised pre-op diet). I know this will probably hurt me because they want to see proof that Ive gone through supervised diets before right? Also, my BMI is just a bit over 40 with no comorbidities (gee did i spell that right??). It wasnt until 5 months ago that I reached that BMI..before that I hovered around 38 and 39.

I too wondered about this. I have 2 healthy boys so far 2, 9. Both pregnancies were great. I lost 25-30lb during each pregnancy, i know its not the norm to loose weight during pregnancy but its just how MY body reacted to pregnancy. I also made sure I ate better during both pregnancies. When I say better I mean lessening junk food, increasing veggies and Protein. HOWEVER, as any other pregnant woman I had the cravings for spicy, sometimes salty, sometimes sugary foods and sometimes I had a big appetite. So honestly thats what concerns me if I were to become pregnant again, will I have these same cravings?? will I be able to eat ENOUGH to maintain a healthy pregnancy and to keep myself healthy?? For this reason, i agree with waiting at least 18 months. By 18 months I hope to be settled in my new eating habits and have lost the bulk of what i need to loose.....

Thats awful that you call and getting the wrong information. Im sure it happens everywhere all the time however, when it comes to policy information reps should always be up to date....considering this policy changed 6 months ago...they should know by now. I finally spoke to a rep who IS up to date. She ensured me that there is no longer a specified # of months within their bariatric surgery policy, which means its totally up to your provider (surgeon) if they decide they want you to be on a MSWLP 1-12 mo's which in most cases they do to help shrink the liver. I asked her how I can best transfer this CORRECT information to my provider and she gave me her extension however calling would be difficult, so my best bet would be to just call them and let them know I spoke with the rep and was informed of this change and the updated policy.....which i did before!

Question.......Could the reason Im getting a different response from everyone is be my employer? Im hearing that policies are also based on your employer. For instance, even though 2 people have the same insurance (BS/CA, Ach Em Oh) lol they may have different policies and/or requirements, based on their employer or the plan that employer has. So that is what this is beginning to look like. BS/CA may not have this requirement anymore, but my employer may have required it specifically in the plan they offer their employees.

Congrats on having a great Surgeons team! seems that it just really depends on who you see, which i know. Here's what I was told by my surgeons team.... "The rep I spoke with says they do require 6 months, if you are insistent on 3 months you can but be warned they will probably deny it and we'll have to do the appeal process which can take much longer......" Even though I gave her a copy of the new policy and Auth form..... Now it seems that I am the only one who is having this issue....with BS/CA and my surgeons office. How are you guys (and others Ive read through the site) being told by BS/CA reps they no longer require the 6 months and had a policy update 7/31...and Im being told by BS/CA reps the total opposite? now i'm beginning to think that this just isn't for me..... I mean, are we calling 2 different companies..far as I know there is only 1 BS/CA...... Sorry for the rant, just very frustrating and disheartening.

Got iT! Unfortunately, I have yet to get in the habit of taking down names when calling to get info but will work on it. Needless to say I dont have any names of the reps I spoke with. I called about 4 times. Funny because the first time I called I was told "We do not have a specific amount of time for the pre-op diet, that is up to your Medical Group. The second, third and fourth time I got "Oh yea,...you are required to do 6 months". Do you think I should start my calls over again just so i could get names this time? I understand that this could be vital information for the grievance.

How are you managing your time off? I pretty much just started this process 2 months ago and I've already had several appts. I feel bad for having to request time off from work so often...and its not over. I have several more appts I need to make (blood lab, ultrasounds, surgeon 2 month followup, NUT 2nd Followup) and so forth. My job is already wondering what the heck is going on with me.... Just curious how everyone is managing their time off with work. Also, the surgeons office suggested 4-6 weeks off from work. Does anyone know if State disability will cover that time? I definitely don't have 4 weeks of sick time saved up, I had a baby 2 yrs ago and since then its been difficult for me to really save alot of time.

BTW- This process is already a PITA!

Thanks so much 2goldengirl! Here goes the update and not a pretty one. The surgeons office called Blue Shield to verify the policy information. Btw my patient navigator was so upset with Blue Shield...she said she was on hold forEVER and that when she finally got someone, they didnt sound very knowledgable.....funny because I felt the same way when i called....They were told that the requirement is 6 months, no less. The surgeons office said if I wanted to I could do the 3 months and they can submit all of my paperwork to Blue Shield however, they will probably decline it and request me to do more or I have to appeal it and they would take "an even longer time". So how can I file a grievance if Blue Shield/CA is telling them the policy states 6 months pre-op....

BTW Blue Shield has been very tough for me lately. They will not give me the # to their Pre-Auth department, and wont even transfer me. I guess all insurance companies are very different in who patients have access to speak to.

Thanks so much for the info and push. Im definitely ready to go forward and do whatever I need to. Unfortunately, im having a hard time convincing my surgeons office that BS/CA no longer required the 6 month pre-op diet. Matter fact, they are saying that it has been raised to 12 months for many.

The Prior Auth form says you have to provide documentation of prior weightloss attempts. How are you all doing that? Does UNsupervised attempts count?

I am so nervous about my 1st appt tomorrow with the surgeon. I have always been borderline the required BMI of 40 (The only health issue I have been diagnosed with is obesity and pcos) . I have been over 40 since September. Before that I have hovered around 38 and 39 with no health issues except pcos. I attended the required seminar over a month ago. Shortly after, I had my first Nutrition visit. Im thinking I should have held off with the NUT visit until after I met with the surgeon but I was in a hurry and didnt know how many months of those visits Blue Sheild/CA would require me to do so I thought Id give myself a head start. I was even told by the staff at the surgery center to go ahead and start the NUT visit but they advised me not to loose any weight because that would take me under the required BMI. WELL I ended up gaining 3 lbs over the holidays. If the Surgeon wants to go by the weight from my first nutrition appt, im hoping she doesn't disqualify me from the weight gain. I guess im not asking for anything here...just some encouragement for tomorrow visit. Is anyone else going through this with no family support?

Thanks goldengirl. Ok, I do have a copy of the policy. I actually started this process a couple months ago and have since then gone to the Seminar, had my first Supervised diet visit ( a month ago) and started all the blood work and getting ready to schedule the U/S and Upper GI etc. I also met with the surgeon for the first time today as well as had my psych eval and passed. The Surgeon wants me to loose 10lbs before surgery...and gave me the diet that I am to follow from now until the liquid pre-op. I am only stuck at this point where the Bariatric surgery center says that If I have B/S CA, then I have to do the diet for 6 months....I told him BS recently changed that and they said they have not received any paperwork stating that change so they are still going by 6 months unless I can provide them with that notice of change. I will send them a copy of the first few pages of the policy and see what comes of it... Thanks so much for that info! I know i sound like a bunch of whining but 6 months is alot compared to 3...not to mention I prefer to have surgery in mid-late Spring, rather than summer.... BTW- I just printed the auth form directly from the providers site and it IS different from what the rep sent me. It does not list the 6 months!!!! matter fact it just says History of weightloss attempts etc....but does not specify how long except minimum of 3 months which is fine by me

and the top of my form says Blue Shield of California... I have ***, does that make a difference? Maybe that is why. or maybe I was sent an old form?? i'm so confused right now... The Form the representative sent me doesn't even have an effective or Revision date on it. Those sections are blank.....

and that's exactly what I keep hearing and reading from posters etc however I just got off of the phone with BS of CA and they sent me the actual Prior Authorization request form that my Dr would have to complete and send to them and it does state that you have to have 6 consecutive months of weight, dietary and physical regimen documented. :'(

Hello- Im new around and have made the first step towards having vsg, meaning that my Dr has referred me to the bariatric surgery center and they have me scheduled for an information session in November. (Ive made an appt with a dietician and a Dr. (to start sleep study process). I have called my insurance company and they said that my plan does cover BS long as it is medically necessary and my Dr submits required authorization. They were not able to answer my question of "how long must I do a medically-supervised diet to qualify" the surgery center just told me to start with 3 months...hopefully by then I know. I have no medical issues besides being obese....I am at the borderline of qualifying with no medical issues. My BMI is currently 40.3. If my insurance requires a 3-6 month diet plan and I loose weight and go under the BMI of 40 does anyone know if they deny surgery from that point? I was also denied by the surgery center about 6 months ago because my BMI was under 40. Now they have accepted me because Ive gained and its just over 40. This whole process is already stressful and I feel like my insurance co (blueshield ca (thru employer) is not giving me direct answers to the questions I am asking.

Thanks so much for responding. So for you they required a 3 month plan? I will call back on tomorrow and see if I can dig for more info. Everytime I call I get a different response and I think that is the most frustrating part of all this....that and the fact that the nearest information session date is so far out!

Hi all, I went to see my doc regarding the LB surgery and she said she was pretty confident that she could get me approved as she was good at doing all the paperwork and whatever was needed. Little did she know my insurance (aetna) would cover the surgery after exceptions, which was fine, even though I am healthy, my doc was not worried and said she knew how to get it covered...BUT my employer will not cover it. Gee thanks job. I HATE my job right now. Ive been here for 5 yrs and had I known 5 yrs ago that I wanted this surgery and they did not cover it, then I probably wouldnt have taken the position, as I had other offers at that time. This SUCKS, and at 231lbs, 5'2,....I need to loose weight badly. This is the response I got from my employer: We have looked into this procedure and determined that due to the serious risks and complications with this treatment, it will not be covered under our plan. Sorry.