I'm at step one of this process & have my appt with the surgeon next month.... so I'm brimming with questions, concerns, etc... with regards to what insurance requires and what may or may not count. I have BCBS AL.....

My question about the diet thing is this: My Endocrinologist (not my PCP) told me to lose weight (because I'm pre-diabetic) and to follow the plan on a paper she gave me. I went back later, and it wasn't every month because she didn't ask me to do that, and I'd gone from 328 to 280 (was a very restricted diet), and it was literally over 6 mos time from when she told me to follow the plan and when I saw her last (about a month ago) and I'd lost that weight. I know my weight goes up and down because it's unbelievably difficult to stick with such a strict diet when you've not had surgery (for many of us it's difficult anyway).

I wonder if that would count as 6 mos of doctor supervised diet since it was a plan she gave me and I followed? The only thing that didn't happen was monthly weigh-ins with her. She's an hour and a half away so monthly weigh-ins would've been a royal pain but she also didn't require or ask me to come in once a month to weigh in.

Any thoughts?

With regards to comorbidity requirements: My BMI is WAY up there, like 50, so I guess I don't NEED to have a comorbidity of any kind to qualify in that respect, but.. I do have the following and wonder if this helps approval?

Pre-diabetes
Arthritis
HBP (not on medication though)
sleep apnea (Can't use CPAP due to intolerance and causing bruising and pain so use an oral device)
High cholesterol
High Triglycerides
Fatty liver (NASH)
Stroke risk (Had a TIA in 2013, heart ablations in 2014 for AFib, SVT, and Atrial Flutter).

Thanks for your patience with all my questions. I'm having difficulty getting my PCP and my former PCP to get back with me about records showing my weight, BMI etc. I've NO idea what I even need from them but trying to be proactive (suggestions?).

Edited March 2, 20179 yr by SummerShadow
Clarification

On 3/15/2017 at 6:04 AM, Middus said:

My BCBS didn't require anything more than BMI > 40 or 35-40 with co morbidity.
Your Endocrinologist's diet should count as a supervised diet.
I was only asked if I had attempted dieting before.. (my surgeon also had me lose a minimum of 10lbs before meeting with me to discuss surgery)

Well, after my first appointment it seems I cannot use my endocrinologist at all but my GP, and I have to have a letter from my GP (had two in 3 years time) stating I was overweight, what my BMI was, and listing any co-morbidities. I also have to have a letter from my dentist who fit me for my oral device for sleep apnea, and I have to have clearance from my cardiologist. It's all a giant mess at the moment as one of my GP's doesn't 'get' what I need from him. He mailed me a clearance for surgery letter but didn't include anything about my being overweight etc from when he was my GP (left him due to horrible nurse, that still works for him, and then went back after other GP was a total waste of time to see). Anyway, so the GP who I left actually knew what I needed and it was done, and I was able to speak to a human being at the office. Former and current GP... receptionist keeps putting me through to records, and records can't help me with what I need. *sigh*

Now, my surgeon didn't require my losing any weight before my initial visit, and... he didn't tell me exactly how much I was supposed to lose to qualify in that respect either... so I still have to call them and ask. But they didn't require me losing any weight to see him the first time, and I'm suspecting he didn't because they had no idea if I were to qualify through insurance or not prior to that first appointment.

I also thought I wouldn't be able to have Gastric Sleeve surgery due to having some reflux. As it turns out... I can, and that most people have improvement of that. So... GS it is if approved.

I also read in my paperwork that they don't require a psych eval, and I thought that was pretty standard. But hey, I'm good with one less thing to do beforehand. Oh, and since I have sleep apnea and am being treated for it... my BMI has to be 30 or above. Currently... my BMI is a whopping 48. Yikes.

Have you thought about going to Mexico for surgery. It's about 4K

jb said.. "Have you thought about going to Mexico for surgery. It's about 4K "

No. I'll stick with the US. Insurance will approve me, I'm pretty sure, but it's getting one of my doctor's to understand what's needed from him, paperwork wise. My BMI is 48... I don't think they'll deny me unless I or my doctor screws up the paperwork.

Sorry this didn't show up as a quote from you jb. Not sure what happened so put your question in manually.

Edited April 28, 20179 yr by SummerShadow

On 3/15/2017 at 8:15 AM, Middus said:

I don't know why Briatric pal posted my response 1 million times though

It wanted to make sure I understood you. hahaha. I feel like I'm having to do that with my GP. ;p No worries.

Did GP refer you to Endocrinologist? Because if he did then that should be in the record, an Endo is a physician for crying out loud, and should suffice for your 6 months. I would ask for an appeal of that decision. Have the Endo and NUT write it up and submit it, worth a shot anyway.

I had BCBS CA I live in TX my company is based in Cali and because my BMI was 40 and complication showed up in my EDG acid reflux mainly ... they waived the 6 month dietitian visit was approved in 1 week I guess my Dr. office does this all the time they knew the loop holes

On 3/14/2017 at 8:05 PM, OutsideMatchInside said:

I used BCBSIL when I had surgery and they didn't require 6 months of anything if your BMI was high enough, and I think that was anything over 40. I went from first visit to surgery in 8 weeks.

Wow. You're lucky! Here in AL they require 6 pos of doctor supervised dieting. I thought it was 7 months but found out at my visit with the surgeon that it's 6 months. I didn't realize when I'd already left the appointment... that they didn't tell me how much I had to lose in that 6 months, and I've been trying to reach the person who handles this for about a week and a half now with no return calls. So I'm still pretty much in the dark.

On 5/11/2017 at 7:28 PM, STRAWBERRY972 said:

I had BCBS CA I live in TX my company is based in Cali and because my BMI was 40 and complication showed up in my EDG acid reflux mainly ... they waived the 6 month dietitian visit was approved in 1 week I guess my Dr. office does this all the time they knew the loop holes

That's great that they did that for you! I have reflux and sleep apnea, and I still have to jump through all the hoops to get this approved, and that's with a BMI of 48. So glad they did that for you!!!

2 minutes ago, SummerShadow said:

Wow. You're lucky! Here in AL they require 6 pos of doctor supervised dieting. I thought it was 7 months but found out at my visit with the surgeon that it's 6 months. I didn't realize when I'd already left the appointment... that they didn't tell me how much I had to lose in that 6 months, and I've been trying to reach the person who handles this for about a week and a half now with no return calls. So I'm still pretty much in the dark.

A lot of times it isn't insurance that requires it but the program. Your BMI is high enough that insurance probably wouldn't require 6 months. I would call the insurance company and verify the coverage with them to be sure.

On 4/29/2017 at 5:01 PM, Sosewsue61 said:

Did GP refer you to Endocrinologist? Because if he did then that should be in the record, an Endo is a physician for crying out loud, and should suffice for your 6 months. I would ask for an appeal of that decision. Have the Endo and NUT write it up and submit it, worth a shot anyway.

I'd been seeing an endocrinologist for pre-diabetes, but now my numbers have slipped a tenth of a point below the cutoff between normal and pre. My Endocrinologist told me to go to my GP to get the process started, and she was one of 3 doctors who suggested I think about getting this surgery. I think my endocrinologist isn't as great as I initially thought.

Just now, OutsideMatchInside said:

A lot of times it isn't insurance that requires it but the program. Your BMI is high enough that insurance probably wouldn't require 6 months. I would call the insurance company and verify the coverage with them to be sure.

I will try that, Outside. Thank you for the suggestion. The patient advocate at my surgeon's office, the one who knows the insurance requirements, etc... was the one who told me I had to do the 6 months of dieting. I wish I understood why it's so hard to get approved for this surgery. Can't just be the cost, because there are a lot of approved surgeries that are approved all the time.

On 3/15/2017 at 5:55 AM, Middus said:

My BCBS didn't require anything more than BMI > 40 or 35-40 with co morbidity.
Your Endocrinologist's diet should count as a supervised diet.
I was only asked if I had attempted dieting before.. (my surgeon also had me lose a minimum of 10lbs before meeting with me to discuss surgery)

Thank you for the input, Middus. BTW, love your avatar. It seems the requirements vary so much from state to state that it's incredibly confusing, overall. But then, that's the way it works anyway... one state vs another.

This is what I found online from BC/BS of AL They really don't make it easy at all. And, it still doesn't say how much weight I'm supposed to lose in that 6 months.

Edited May 15, 20179 yr by SummerShadow

It is hard because they make it that way on purpose. Obese people are still a group of people that it is okay to discriminate against.

A lot of WLS programs make people jump through pre-op hoops to prove they are "worthy" or surgery and will be compliant hoping it will lower post-op complications.

In the past insurance has made it difficult for people to get approved because they thought WLS was expensive. Now with Diabetes increasing and the cost of diabetes being so expensive, a few years ago a lot of insurance companies eased the path to WLS because it is more cost effective for them to get people to surgery ASAP.

I got my ball rolling my BCBS by calling them, verifying my coverage. Finding a Blue Center of excellence, and going there for the seminar. Going through my normal Drs was absolutely useless. I went to the Bariatric program and then they told me what I needed from everyone else, and I just hounded everyone to get what I wanted as fast as possible. So I went from first visit to surgery in 8 weeks.

ETA:

I read your prior post, which you wrote while I was writing my post. That sucks but you need to get rolling on this 6 months ASAP if you want to have surgery this calendar year. The year is already almost 1/2 over.

Edited May 15, 20179 yr by OutsideMatchInside

On 3/2/2017 at 3:41 PM, LeaninLanc said:

I have BCBS of Minnesota. I had similar questions so I called the BCBS offices and spoke with someone about the six months requirement and also had it emailed to me so I would be fully educated. I think that's a good starting point.

Thank you.