DENIED

I called OSF ins today and was told I was denied again  . My pain doctor has tried to help me over the last three years diet pills, nut, exercise etc...  I have lost some with the food mover, Richard Simmons, water exercise but gained it all back.  I have a bad back and every time I get a steroid injection it increases my appitite. 

Presently I am in the process of getting the nerves zapped  in my lumbar area to reduce pain   .  This should decrease my need for the steroid injections.  So I had doc send all the information she had but of course it isnt enough. If you didnt chart it , you didnt do it.

OSF wants 12 months of supervised wt loss within the last three years.  My question is: I weigh 285 have high bp, lupus that causes joint pain and repetitive movement causes bursitis and tendonitis,and I have back problems.  If I show  that i am compliant loose enough weight I put myself out of the band dont I?  If I dont loose weight then they can say I wouldnt be successful with the band, right?  I have not weighed less than 230 in 15 years.  The weight always comes back.  How do you get qualified at this point?  What do they want to see? Any help would be appreciated   Lisa

Hi Lisa -
I'm sorry about the news.  Don't give up.  Unfortuanately, if they say you have to do a 12mo supervised diet, there is probably no way around it.  Your gonna have to do it and make sure you go to every appointment each month.. weigh in, have the doc sign off that you were there and make sure you don't miss any appointments or you may have to start over or go a month longer.  It all depends on what the requirements are thru the insurance co.  I would first get clarification are they looking for history of your weight for the past three years or the actual 12mo sup diet.

Stick it out, it seems like a long time but these darn insurance companies want you to give up.

Christina

Hi Lisa, Please call your insurance company and ask what it is exactly
that they need, ask them to tell you what they have. It might be a simple thing as one of the many doctors didn't submit thier information, or it was misfiled.

We are all here for you,for support whenever you need it.

Hugs

Hi Lisa

Hang in there.  It is frustrating when insurance companies give you the run around.  Do contact your insurance company and ask them to send you in writing just what they require for approval.  Then you know EVERYTHING they are wanting.  Many times they will play the denial game hoping you will slink away and not pursue this.  Dont let them get away with this. 

I had to do a 6 month diet twice (long story).  I did not really lose any weight during that time but it met my insurance companies requirements.  I yo-yoed in my weight all year long.  Typical.  Could not exercise due to severe arthritis.  My insurance company did not really care whether you lost weight or not.  Just wanted a 6 month diet (make you go away tactic)

Good luck and dont give up! 

Dear Lisa:

I am sorry to hear that the insurance company is giving you a hard time, but that is their job.

If they want a supervised diet, that is what you will have to do.  As Christina said....once a month, every month with notes.  I actually made up a form for my doctor to fill out with the information that the insurance company wanted to see.  That way, I knew that her notes would be complete according to the insurance company.  One time, my doctor was going to have me be seen by a student (since it really IS only a weigh in formality) but I told them that I wanted to see the doctor.  I was NOT going to have the insurance company say I missed a month with the DOCTOR.

At first, my insurance company's requirement was 1 year, but in my 9th month, I found out that they had decreased that to 6 months.  I sent in all the records and was approved within a week.

Hang in there and do not give up!

I am going to echo what the others have already. It is great that your pain doctor has been helping you through some of your difficulties but that is not what OSF is looking for. Do you have it in writing exactly what they want done with the supervised wt loss trys? Ask OSF what weight they use after the 12 month supervised diet try. Do they want supervised weight loss OR supervised weight loss trys? There is a difference. More than likely it is your first weigh in. They are looking for if you can follow a discipline usually more than weight loss. Any loss will be great before WLS and safer for you if and when you have surgery.  It all needs to be charted that you were into the doctor, was weighed and you and the doctor discussed the issue of you loosing weight. Make sure it is the doctor and not a PA or student helper that is doing the charting. Just make sure it is all in the notes on your chart. The insurance does not want a summary of your weight loss trys.  Many people do not loose weight on the supervised diet try. That does not mean that you will not loose weight with either the band or say a person that is going to have RNY. There are many factors that go into loosing weight. Scientists have discovered that there are at lease 19 hormones that dictate a persons ability to loose weight, hunger and being MO. How do you get around that? Of course they have found that the person having the restriction with the band, going on a low calories diet with a component of exercise with most definitely help a person to loose weight and keep it off.

Thanks everyone.  I just got it in writing today.  It said physician supervised weight loss plan with four visits in 12 months. Went on to say what types of wt loss plans are accepete, w****cher, dietition visits etc...  I will call the GP tomorrow and make an appointment.  I will continue to hold onto the possibility of since OSF was bought out by Humana changes may be made.  They actually start with the new plan in January so wish me luck that it changes to 6 months by then!

Heres to another diet   LIsa

Well, now you have something to shoot for. Those four months will go by fast. Use that time to start learning life style changes for when you are PO.


CB