Question:
I was denied a Bariatric Consult

I have Blue Shield HMO- Access Medical Group. My PCP made a referral for a Bariatric consult. Well I was denied because "its not medically necessary". Does anyone have any suggestions/advice on what I should do now. I did not go to my PCP for the surgery I went for a annual physical, she suggested it to me. I have been researching surgery for awhile but I have been in school my health has taken a back seat :(. My BMI is 60 but I have no "other health issues". I have migranes, knee pain, back pain, etc. But I guess my BMI does not warrant me to have this surgery. Its not an exclusion . Its covered if its medically necessary I guess. No one has told me the criteria.    — fattykoo30 (posted on June 4, 2005)

June 3, 2005
My initial referral to my surgeon said general surgery. By then NIH standards with a BMI of 60 you do qualify but each state has different laws governing how the handel their medical insurance companys. Did you call your insurance company and request information regarding Bariatric surgery? Or actually you should call the surgeons offic and ask for the code and give the code when you call the insurance company. Take names and times and ask them to send what they've told you in writing. Don't give up if it's something your actually interested in, in the mean time see your PCP and start a physicians supervised diet so that if that becomes part of the requirement you've actually started it already. Good luck Denise
   — dlryanoates

June 3, 2005
I had BCBS HMO Illinois and the requirements for me was 2 years medically supervised diets plus it had to be medically necessary. It was my PCP that found out the requirements and put me on a plan to meet them. I wholly believe that HMOs are only as good as your PCP. If he doesn't fight for you, it won't happen. When the surgeons that I contacted tried anything, they were referred back to the PCP. Get on your PCP and if he won't do it, get a new PCP. It will happen for you but be prepared to jump through some hoops. Hang in there!!! God's Blessings!
   — David B.

June 3, 2005
I would go back to the doctor and tell her to help you appeal there decision. A BMI of 60 is more than enough evidence that you need to have the surgery performed. I would even ask the doctor to tell the insurance some reasons why you should have it. Knee pain and back pain are really good reasons! I hope this helps. Good Luck! Jenifer
   — JeniferJulie

June 3, 2005
You need to find out from the insurance company what they deem medically necessary. The joint pain (knee and back)is part of what the NIH considers as medically necessary. Not all states have laws that require or mandate WLS, in fact there are only a handful. And even then the different states all have differing guidelines that they follow. So they may not go by the NIH "guidelines" or suggestions. So again, ask the insurance company what they deem as medically necesary and then send them any supporting data. Michelle "Pookie" Engelmann Vice Chair Maryland Task Force for the Study of the Utilization and Review of the Surgical Treatment of Morbid Obesity
   — Michelle E.

June 4, 2005
I would imagine just by your BMI being so high that you should qualify. I don't see why they wouldn't allow you a consult especially with the joint and back pain which is part of your weight issues. I would talk again to your doctor, perhaps if they write a letter saying that medically because of your weight you are considered high risk that you will be able to qualify. I know your doctors backing is very helpful in this situation. I was only a BMI of 47 and was able to get a referral. So don't give up keep fighting it and I am sure you will eventually get what you need! But be sure to talk to your doctor again soon.
   — lorie_nicole

June 4, 2005
Most WLS will operate if you are BMI 40 or more, so yo9u fall within the guidelines. You need some help to get over this hump.
   — Lise K.

June 5, 2005
Hi Teresa, I have been researching WLS on this web site for a few months now and a similiar question came up...someone said make sure the correct "code" was used. Not the code for "obesity" but the code for "morbid obesity". Some primary care dr staff will code it wrong when it is submitted and it will be denied. I can't find my notes right now giving the code, but if my answer isn't clear e-mail me and I'll find it for you. Good Luck, Sue T
   — lovey063

June 5, 2005
Well, with a bmi of 60 and no medical problems, you should still qualify. I know with my surgeon, if you are under 45 or so with medical problems, you qualify and if you are over that without medical problems you qualify. So, I guess it depends on how your particular insurance and surgeon looks at it hon. Hugs
   — Angelfirewithwings

June 5, 2005
Teresa, Maybe it is because Blue Cross has discontinued allowing people to have the surgery. I would say you qualify, but that is the only reason I could come up with. Good Luck!
   — Kevin R.

June 6, 2005
Keep searching!! I don't have any of the more common medical problems with my obesity but I do have a BMI of 60 also. I also have knee, hip and low back pain. My doctor said the BMI of 60 was enough. That is considered super morbidly obese by some charts. Remember morbid means unhealthy, so we are unhealthly obese. Keep looking for a good bariatric surgeon. Make sure he or she is board certified, with such a high BMI you don't want just anyone that will do surgery on you.
   — Patricia C.

June 7, 2005
Denial Letter Original Post by Teresa Smith at 9:43 PM PST on 06/07/2005 Los Angeles, CA This is what I received from Access Medical Group: Based on the information provided patient does not meet established guidelines for Office consultation at this time. The clinical information indicates that a consult for bariatric surgery does not meet Access Managed Care criteria at this time. Criteria for bariatric surgery is patient must have diagnosis of morbid obesity defined as a body mass index greater than 40, or greater than 35. When co-morbities are present, including but not limited to hypertension,obstructive sleep apnea or diabetes. Your records do not indicate diagnosis of morbid obesity defined as a body mass index greater than 40, or greater than 35. When co-morbities are present including but not limited to hypertension, obstructive sleep apnea or diabetes, therefore this request is denied. Please contact your Primary Care Physician for further assistance. My mouth dropped. My current weight is 343 OMG My BMI is what....... I called the medical group, the person I spoke to stated "it seems your PCP did not provide your weight or BMI" I was told to have my PCP resubmit. Any suggestions? Should I resubmit or appeal through Blue Shield. I emailed Blue Shield they responded with I need to appeal with the medical group. My letter reads my appeal goes through Blue Shield. This letter proves to me the surgery is covered if my BMI is greater than 40 without co-morbities. The medical group is going to send me a copy of the actual benefit provision, guideline,protocol or similar criterion on which the denial decision was based on. With this news.... I do not know what to do. If its covered I wonder if the same criterion will be used if I switched to Blue Shield PPO....... Any suggestions is greatly appreciated. T
   — fattykoo30

June 7, 2005
GO BACK TO YOUR PCP! It sounds like, though they were well intentioned, they did not follow the proper protocol. Your PCP needs to give you the medical diagnosis of Morbid Obesity and list your co morbidities for the insurance to see when they resubmit the referral. THen, you should be fine. Good luck!
   — LMCLILLY

Click Here to Return