Dr's Office and Insurance question

MS_mom_1965 · November 28, 2006

My ins co requires a 12 month supervised diet. I don't have that. I have around 6 mos of WW is all (that I can document). The dr's office says they won't even file the ins since I don't meet all the requirements. I've seen several other posts where people have been approved since they have co-morbidities. Is my dr's office out of line? Should I contact a different doctor, or this standard practice?:cry

Kat817 · November 28, 2006

That was the one where my insurance got me as well. And they would not budge. It could be that your Dr.'s office has dealt with it before. Have you talked to the insurance company to see if they are willing to do it without? If the Dr.'s office is unwilling, you can see if the HR person at work (or wherever the insurance is through) might make the call for you.

I have Blue Cross Blue Shield of TX, and I was attempting the 12 months, but at 10 1/2 months into it I was injured in a car accident. I ended up in surgery etc, and my regular Dr. visit was interupted---and they were going to require me to begin the 12 consecutive months over again. I appealled, and was denied again. In the end I used the settlement I got from the accident and self paid.

BUT you are right, some others have hired an attorney, and managed to work around insurance issues. I was impatient!!!

Also did you talk to the office manager at your Dr.'s? Some times you end up with a receptionist who is not the one to make that call. I fully believe I would mention my unhappiness at the way it was stated to the Dr. My niece is my PCP's office manager--and I told her the door said "office manager....NOT GOD".

Good Luck!!! There are several on here who have written letters to the insurance fighting an appeal, you might ask for pointers if it comes to that.

Kat

juliegeraci · November 28, 2006

This is not standard practice. My doctor has a BMI index you have to meet. I think its 40%. I was 282 lbs at 5'8 so that might give you a feel. In any case, I think it is best to chose a doctor that support bariatric surgery. God only knows we can come up with some other diet plan we followed for 6 additional months ie. low carb, low fat, counting calories. Good luck to you. I know you probably are yearning to get this over with and move on with your band!

LuckyGirl · November 28, 2006

i too have BCBS TX and i started a year ago and was denied and told that i had to go on the 1 year of a doctor supervised diet. I went to an internist in december and then for some reason - i think she cancelled - i didn't go again util June. I went in June and had blood work in july, i went again in august and sept. and then i found out that BCBS had switched to 6 months. So i went in October and then i had my bariatric surgeons office submit again. I was denied because my bmi was around 37 and my doctor had not specifically diagnosed me with 2 conditions. So, i went back and said, "look, you have me on diabetes medicine and my cholestrol has been continously high - I need you to write a formal letter telling them I have 2 conditions - your notes are not specific enough for them. She did and we appealed again. This time they said i had proved the 2 conditions so that was good but now i had to show continous 6 months and they had it starting in June - So, i went back to the dr. in november and made an appt. for dec. just in case i had to go back. We sent in another appeal after that last appt. and after 2 weeks of waiting and calling every day - morning and afternoon - got an approval yesterday! Yikes, it has been a pain but well worth it now that I know I can have the surgery and have it paid for!!!!!!!!!!!

So, MS MOm, i was told that ww counted if you could prove it somehow. and I would find a general practitioner - i have an internist who i've been going to who sees me regularly and faxes my info upstairs to the surgeon's office who sends in the letters to the insurance co. i don't know about where you are but this is becoming a Big Business. There are several doctors doing it in my town and tv commercials all the time. It's easy here to find someone to do it and if it's a bariatric clinic or office specializing in lap band they should have an insurance coordinator who is very proactive!

ReneBean · November 28, 2006

Well - you can fight it on the basis of what the FDA requires - which is just evidence of prior attempts - no time limit involved. But keep in mind that I had to make appeals for like four months - so you might almost just finish out your 12 mos on WW - if you know what I mean.

If you e-mail me, I will send you my research links and my letters.

:]