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Scheduled And Insurance Denial



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Hi all - Going with a surgeon in NJ and completed all my preop requirements and they submitted for approval on 1/10 anticipating a surgery date of 2/8. I called insurance to get a heads up and they said they just sent out a denial today for not enough information, specifiying 5 year history and also a 180 day weight loss program, which my surgeon never mentioned. I started the process in September so if i knew i had to be in a specific program, i would have started. I havent talked to the surgeons office yet but i am guessing 2/8 is out of the question. For reference, i am 39, 5'6, 360 lbs and i have been over 300 since 2010. What do they typically need and who does the supervised diet?

My other concern is how long all this testing i just did is good for. I had a stress test, stomach ultrasound, echocardiogram, lots of blood work, upper GI study, psych eval, and all required nutritonist appts. am i going to have to do this all again?

Edited by DTB583

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So the 5 year history typically means they want to know how long you've been obese, what comorbidities you have and how long you've had them, what meds you've had to take for them and how long, etc... The supervised diet would be either 6 months working with a dietician or having done things like doctor supervised Keto, or Jenny Craig, or Weight Watchers, or a low calorie/low fat diet (again, doctor supervised). If you have done any of these, they want to know the results.

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My Dr made it really clear at my first appointment that it is the patients responsibility to call and get exact specifications on what your individual insurance requires. They even made me sign a form stating they are not responsible if I don't call them and then later get denied. I have Aetna and I have to complete 12 dietary appointments (no specific time frame) as well as the list on clearances. I know other insurance companies require 6 or 12 months of dietary appointments.

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41 minutes ago, viviand said:

What kind of insurance do you have? Self pay or through your job?

Meritain, it’s part of Aetna. It’s through my job though i still pay a lot lol

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36 minutes ago, SleeveDiva2022 said:

So the 5 year history typically means they want to know how long you've been obese, what comorbidities you have and how long you've had them, what meds you've had to take for them and how long, etc... The supervised diet would be either 6 months working with a dietician or having done things like doctor supervised Keto, or Jenny Craig, or Weight Watchers, or a low calorie/low fat diet (again, doctor supervised). If you have done any of these, they want to know the results.

I mean, i have doctor records from physicals 4-5 years ago that have my weight and everything. I haven’t had any medical problems yet, just slightly high cholesterol. I have been a member of weight watchers for years but off and on.

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17 minutes ago, kla7403 said:

My Dr made it really clear at my first appointment that it is the patients responsibility to call and get exact specifications on what your individual insurance requires. They even made me sign a form stating they are not responsible if I don't call them and then later get denied. I have Aetna and I have to complete 12 dietary appointments (no specific time frame) as well as the list on clearances. I know other insurance companies require 6 or 12 months of dietary appointments.

In my handbook it does mention it being needed and i told the coordinator at my surgeon who said that my letter of medical necessity should suffice for that considering how overweight i am. I guess i will see what i can gather.

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your PCP's records of your weight for the last five years should count for that five-year requirement. For supervised diet, usually people work with their PCP or a registered dietititian (although some insurance will accept things like Weight Watchers, if it's documented - you'll have to ask them). You shouldn't need to have any co-morbidities at a weight of 360. Most insurance companies don't require you to have co-morbidities to approve the surgery unless your BMI is under 40.

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