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Caresource Ohio requirements



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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.

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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!

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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.

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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

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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.

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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

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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.......

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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.

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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!


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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.

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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

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