HELP........Need your advice!

Hi Cathy, Is Katie a State of Arizona employee? Seems that is where the problem is. I was told that there was an exclusion that would not cover by-pass. I have had a sleep test, cardiac clearance, psych eval. etc. Thank you for responding. Vicki

Hi Vicki, I am in the same boat as you are, State of AZ employee with UHC EPO. I've attached a list from the policy intent document regarding the state's requirements for WLS, which is above and beyond UHC's requirements. Basically, I took each one of the requirements and found documentation to support how I met it. I have not submitted yet and I am hopeful they will approve. My only concern is that my "6-month supervised diet program" was supervised by my MSW counselor and not a doctor, but fingers-crossed and prayers, I hope they will approve. I was also told that they tend to deny the first time out regardless so I wish you luck on your appeal. Hope this info helps. Take care, Sandi State requirements: 1. Documentation of 5 years history of severe obesity 2. Documentation of 6 consecutive months participation in a physician-supervised weight loss program (including monthly weigh-ins, nutritional analysis, education and at least monthly encounters with a health professional) documented by a physician who does not perform weight loss surgery, within the past year. 3. The weight loss program should include all of the following physician-directed components: ? Dietary therapy & increased physical activity ? Behavioral therapy to reinforce dietary therapy and increased physical activity ? Consideration of pharmacotherapy with FDA-approved weight loss drugs Must include ALL of the following: 1. Psychiatric assessment and approval 2. Medical assessment and approval 3. Nutritional Counseling 4. Exercise Counseling 5. Psychological Counseling (licensed practitioner) 6. Support Group Meetings Diet programs/plans alone, such as Weigh****chers®, Jenny Craig®, or similar plans, are not considered physician-directed weight loss programs. Physician-directed programs consisting exclusively of pharmacological management are also not considered physician-directed programs. Documentation from the medical records indicating that consistent reason-able efforts have been made by a physician to manage the co-morbidities using standard medical protocols. Inadequate treatment of a co-morbid condition should not be used as an indication for gastric bypass surgery in those patients with BMI's between 35 and 39.9. 4. Coverage is provided at In-Network providers only. Network vendors are to scrutinize providers. 5. Criteria: 100% overweight (ideal body and/or twice ideal body weight) with a BMI of 40 with clinically serious medical condition of obesity: life threatening cardio-pulmonary problems such as: hypoventilation, severe sleep apnea, Pickwickian syndrome and obese related cardiomyopathy, clinically unmanageable diabetes, hypertension, life threatening cardiomyopathy problems, coronary artery disease, obesity related pulmonary hypertension. 6. Age: must be between 18 and 55 years of age. 7. All patients should undergo careful selection after evaluation by a multidisciplinary team including documented medical, psychological & nutritional evaluation. A pt should be acquainted with nutritional needs & the physiologic & behavioral changes necessitated by the surgery, as documented by a physician or healthcare professional. ? Primary Care Physician (PCP): each candidate must have a primary care physician, a physician who practices in the community in which the prospective patient resides. That PCP must perform a physical examination on the prospective candidate for weight loss surgery, and provide written verification of (1) the examination and findings; (2) that the prospective candidate is medically stable and able to withstand surgery, and (3) agree to provide follow-up care after the surgery. Psychological Preparation: If the prospective candidate is under the care of a licensed mental health professional, that professional must provide a written verification that (1) he/she is treating the prospective candidate; (2) agreement that wt loss surgery is appropriate for the prospective candidate. Each prospective candidate must pass standard psychological screening test (such as MMPI). Absolute Contraindications (situation in which approval will not be granted): Pregnancy, lactation substance abuse Severe or uncontrolled psychiatric disorder (schizophrenia, borderline personality disorder, uncontrolled depression, bipolar disorder) Relative Contraindications Unstable medical condition The above guidelines are subject to change based on new clinical evidence of adverse outcomes.

Hi Vicki, I work directly with UHC State of Arizona for Dr. Juarez and Dr. Fang. UHC State of AZ requires a specific 6 month physician supervised diet. If you have a BMI of 39 with co-morbidities as you stated above and a 2 yr. documented history of that, as well as a completed 6 month diet you should not have problems getting approved for surgery. Good Luck!