Insurance or Medical Group Requirement (same as main board)

Insurance or Doctor requirement My PCP wrote a request for a referral through our HMO to a surgeon for bariatric surgery. I receive a call from the medical group referral person stating that "I could not get a consult with the surgeon until I have lost 10% of my weight and kept it off for 6 months." Has anyone heard of this? My doctor is on board that I need the surgery. That with a BMI of 40 and a long history of weightloss and then additional weight gain this is what I need. Heck, I lost 30 lbs while I was pg last year and after my daughters were born I gained it all back plus more! I tried to explain to the referral lady that if I could lose 10% and keep it off I wouldnt need the surgery and she said that it the requirement to prove that I could follow the diet necessary post op. Also, since my BMI is 40 if I lose 10% of my weight I will no longer be a candidate for the surgery as my BMI will drop to 35 and except for joint pain, high cholesterol and shortness of breath I dont have any other risk factors, ie, high blood pressure, diabetes etc. Anyone have any insight on how to proceed or if the medical group is just giving me the run around and I should try to deal with the insurance company directly. Like I said my doctor has agreed to the surgery but I cant get past the referral department to proceed. Thanks! Laura

Hi Laura: I am also having the same problem at Kishwaukee Community Hospital in DeKalb, IL. They want a 15% weight loss prior to schedling surgery. I totally agree with you that if I could lose 15% of my weight, I could probably lose more and not need surgery at all. I don't understand why they want you to diet when the whole purpose of having WLS is to make it impossible to overeat and/or consume large quantities of food. I was told that the weight loss is necessary to decrease the size of your liver which is in front of the stomach. The weight loss shrinks the liver and decreases the amount of fat in the liver thus making it easier for the surgeon to get to the stomach. I had horizontal banded (staples) WLS 20 years ago and it failed as most surgeries at that time did because the staples eventually came loose. There was no such requirement then to lose weight before surgery. And, believe me -- you have no choice except to eat only minimal amounts after surgery so it stands to reason one would stay on a restrictive diet after surgery. I don't believe this is a requirement at all hospitals and am trying to find another provider in my area that accepts Medicare for payment. Hope the above info helps .... Regards ...... Linda

Linda, Thanks for your reply. I called the insurance company last week to verify their requirements and whats funny is that they require one year medically supervised FAILURE of diet. THe medical group is requiring 6 months of success so if I do what the medical group insist needs to be done they are GUARANTEEING that the insurance company will deny as no longer medically necessary. I have requested a copy of the insurance company requirements so I can fight and possibly pursue other action against the medical group as my insurance company says I have benefits available for WLS. I will keep you posted. Laura