Medically necessary

[Charisse Jordan 4]

Just wondering if anyone knows if the 6 or 12 month diet plan would be waived if my Dr determined it is medically necessary for the surgery. I found out I have a brain disease that puts me at high risk of stroke. I’m worried my insurance Blue Shield of California won’t approve it without me doing some sort of failed diet plan first otherwise I’ve completed everything else and am just waiting on approval

[Jeanniebug 472]

I wasn't put on a diet plan. I just had to have 6 monthly visits with the nutritionist. My surgeon wanted me to lose 10-12 pounds before surgery, but my insurance didn't. However, I was not allowed to gain weight.

[catwoman7 10,867]

that's a question only your insurance company can answer...

[RickM 1,747]

Ordinarily, no, it's hard to get the companies to waive that - it's one of the roadblocks that they like to use to encourage patients to go on their own and self pay, so they don't have to pay for it - but if there is a viable medical reason for skipping it, then it's a matter for the surgeon to convince the insurance company of it. Usually, that takes about as long as doing the 6 month diet, so one should plan on it and get started, and just hope that maybe they can shorten things a bit.

[Teason4 3]

I am waiting on my approval and my primary physician had to fill out a form the last five years of weight history and also medical history

[St77 85]

On 1/24/2023 at 10:43 PM, Charisse Jordan said:

Just wondering if anyone knows if the 6 or 12 month diet plan would be waived if my Dr determined it is medically necessary for the surgery. I found out I have a brain disease that puts me at high risk of stroke. I’m worried my insurance Blue Shield of California won’t approve it without me doing some sort of failed diet plan first otherwise I’ve completed everything else and am just waiting on approval

As someone else said, only your insurance can answer that. However, with a neurological issue, your surgeon may require neurological clearance for surgery. That's what happened to me. I have seizures and while I had every other criteria met, my surgeon required neuro clearance (my insurance didn't).

[Charisse Jordan 4]

So this happened! I was denied by my insurance because I did not do a year of a weight loss medication first. I cannot take them because my Dr said there isn’t one that won’t interact with my anti depressants so I will fight that. Insurance also said they have no records of having co morbidities that are made worse by obesity. I have a brain disease that puts me at high risk of stroke if I don’t get the weight off as well as GERD and osteoporosis through out my body. I guess the girl handling my pre approval didn’t find out what was needed to get me approved and get the right documentation, now I am trying to get everything for her to turn in with the appeal. I’m a little irritated but I will fight this, getting approved is the only thing left to do, I have come too far

[Decemberluv 0]

My insurance also needed a health complication like diabetes, high blood pressure etc to be approved along with 6 months of weight loss. Due to needing the surgery as a revision to correct major complications from the previous surgery a disingenuous hack did to me, my insurance can wave the 6months requirements with medical proof of those complications. My new surgeon's office informed me that the insurance can backtrack my doctors visits for those 6months. My PCP and Gi are willing to send the necessary paperwork to my insurance telling them that the revision surgery is medically necessary due to the continued deterioration of my health.

What helped me a lot was a case worker from my insurance. Request one to assist you. They will collect all the necessary medical information that your appeal needs, a long with being an advocate for your well being.

[Charisse Jordan 4]

Thank you so much!

[turn132 2]

Have you seen the nutritionist? Normally they do require you to do at least that. I know for myself I had a virtual visit with the nutritionist and I just had 2 pre op nutrition education things online to complete. But sometimes it's what your doctor write in their notes and put as your diagnosis that will either help or hurt you when it comes to getting approved. My diagnosis was Obesity, but I also had Osteoarthritis in multiple joints as one because I told him my knee do hurt sometimes, and I also got a Severe sleep apnea diagnosis as well, all this is because of the obesity. I wasn't put on a diet plan but was given medicine to take just to lower my weight by 5%. However, I did mention at the beginning that I have taken medicine before had multiple failed attempts at losing weight and keeping it off.....I hope you have success on this fight on getting approved. I started my process June 2022 and got approved Jan 2023, surgery Feb 17, 2023... FyI my insurance at the time was Blue Cross *** of LA and Healthy Blue Medicaid.....

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[consuelo1957 45]

So this happened! I was denied by my insurance because I did not do a year of a weight loss medication first. I cannot take them because my Dr said there isn’t one that won’t interact with my anti depressants so I will fight that. Insurance also said they have no records of having co morbidities that are made worse by obesity. I have a brain disease that puts me at high risk of stroke if I don’t get the weight off as well as GERD and osteoporosis through out my body. I guess the girl handling my pre approval didn’t find out what was needed to get me approved and get the right documentation, now I am trying to get everything for her to turn in with the appeal. I’m a little irritated but I will fight this, getting approved is the only thing left to do, I have come too far

Im not sure why they make you do all that my doctor in az ua awesome. I hust had to do 2 visits with phyciatris and get my heart doctor to clear me and a clearance from lung doctor and i had to be on a 1500 calorie daily drink 5 bottles of Water daily took me 3 months and got approved within 1week

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[mkellee 47]

Just wondering if anyone knows if the 6 or 12 month diet plan would be waived if my Dr determined it is medically necessary for the surgery. I found out I have a brain disease that puts me at high risk of stroke. I’m worried my insurance Blue Shield of California won’t approve it without me doing some sort of failed diet plan first otherwise I’ve completed everything else and am just waiting on approval

It also depends some on when your Dr submits it. I have blue shield of California also. I only had to have 3 months of nutrition classes and they submitted and got approval. My problem was covid kept filling the hospital.

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[Neonurse 0]

I’m just getting started. Have Anthem BCBS. Trying to get the information I need to do.