CROSS POST - DENIED BY MPLAN

Post Date: 11/14/07 4:46 pm I am so mad right now!  I have MPlan insurance which is "going out of business" as of 12/31/07. According to the doctor's office insurance lady, they denied me due to lack of 6 month medically supervised diet.  However, she is going to call them back tomorrow because she says they never approve anyone to see the surgeon without reviewing the weight loss history and accepting tthat history and they DID authorize me to see him. I have been going to my PCP each month to weigh in and so far have lost 18 lbs. in 2 months - so that is a plus. What has me so mad is that they know that time is running out and all they need to do now is drag their feet and they won't have to cover WLS for me. After the first of the year my insurance company will be Anthem/BCBS.  How difficult will it be to get approval through them?  I have already had my psych eval - anyone know how long that will be good for and would Anthem accept it? I am not giving up yet with MPlan but guess am just trying to be realistic and think that maybe I won't be having surgery before the end of the year. Thanks.

I am sorry you are having a difficult time with your insurance.  I don't know which Anthem/BCBS plan you will have but that is the insurance I have and my approval came in less than a week.  I had done my 6 month medically supervised weight loss plan (did Optifast), psych visit, letters from several of my doctors and the approval went without a hitch.  So maybe you just need to wait until January and try with your new insurance if this M-Plan doesn't work out.  Hang in there.  It is worth waiting a few weeks if you have to.  Keep your chin up!! Peggy

I have Anthem right now,too. I called 2 months ago to find out what they required for WLS so when I do swith to Anthem BC/BS in January i will have atleast what I needed , It was like pulling teeth to get any info from the lady. So i just hung up. I am hopimg it might be easier thru BCBS being a bigger Insurance co. Lord Knows with what My premiums are they better cover it.and fast!

So, did you get any information from ANTHEM?  One person has told me that a 6 month diet is required - but then another timem when i called and spoke to a different operator she never mentioned it.

Am curious to know what if anything they told you.

Sorry I meant I have Mplan Now OOPS!

I know exactly what you mean.  I also have MPlan.  I had to go through a bunch of stuff to get approved.  I had to see my PCP 3 times; dietician 6 times; 12 week therapy group; and the Psychologist 3 times.  I had my 6 month stuff done Oct. 8th.....saw the Psychologist for the last time.  She did not even call in a verbal okay until last Fri.  The bariatric center called me yesterday and told me that I couldn't have it done until next year.  Boy was I upset!  I told her I'd talked to my surgeon's office manager (this is a revision; had VBG 10 yrs. ago) and she told me that if I got everything in this month, I should be able to have it next month.  I see the surgeon next Wed. Today the bariatric center called to set up my appt. to talk to the Psychiatrist at the center.  They had trouble getting the computer to take my appt., so they're going to call me back tomorrow, but it should be around Dec. 3rd.  My Dec. surgery is still depending on getting everything done in time.   I wouldn't give up on them yet, but you're like me.....time is definitely running out.  We could have Anthem, but if I do, my PCP's office is not taking Anthem insurance anymore because they keep wanting them to take less and less money and charge the patient more.  I'll probably be going with Advantage, but I'm going to Clarian North now for the surgery and I'd have to go to St. Vincent's.....and that's even IF the insurance covers WLS.   I had Anthem when I had my first surgery and they covered it.  Alot of people say that they do cover it fairly easily....one person in my therapy group is going through Anthem next year because she had pneumonia and had to take all of her sick and vacation days that she was saving for the surgery.  She seems to think that she can get it approved easier than MPlan. 

Good luck and don't give up!  I'll be praying that you can get this resolved before the end of the year. Candy

I have Anthem and I hardly had to do anything.  The insurance dont require the psych eval, but my surgeon did.  All I had to have with Anthem was 5 yrs worth of medical records showing weight documentation and the surgeon's ofc didnt even have to send that in. Just have to have it in case the ins. co requests it.  All they done was fill out what is called a tool. It is just a form the insurance ladies at the surgeon's ofc filled out, basically saying that it was medically necessary, what my BMI was, etc.  It was really easy. I was approved within 1 week of the insurance co. receiving my paperwork and had my date within 2 wks after that.  Good luck!

Jenny

Hi! I started my journey off with MPlan as well...back when 18 months of supervised dieting was 'norm' (and legal). I had 2.5 years of proof instead. They denied me. I appealed and had to go in front of an appeal board. And they upheld the denial. Why? They didn't like the way my physician kept his visit notes. Were they going to coach him on what they REALLY wanted? No. I was to just keep going to him for an additional 18 months.  I switched to Anthem BC/BS that January afterward. When my stuff was submitted, I had my approval in less than 2 weeks..submitting all the same stuff I had submitted to MPlan. Here's a note about insurance companies though. Each insurance company (ie Anthem) writes up specific policies according to what the place of employment (ie Lilly's, ) is willing to have in their policies. The more coverage, the higher the premiums. Many companies such as Lilly's offsets the cost of the premiums for their employees as part of their benefit package. If they are willing to offset the cost themself or are willing to allow their employee to pay a little more, they'll include weight loss measures (or smoking cessastion, dental, etc). In other words, just because Anthem covered mine at 100%, it doesn't mean that your Anthem policy will cover yours...or cover yours at 100%. Also, the company you work for can also help dictate what measures it wants you to take for approval. Just because Jenny needed very little doesn't mean you won't either. Your best bet is to wait until you are an Anthem member and call them and as****il you have that member #, they will have no idea what policy you are covered under. One thing for certain, MOST (if not all) will require 6 months supervised dieting and 5 years of being obese. Some will also require eating & exercise journals ****pt mine on an Excel sheet), past weight-loss attempts (weigh****chers, diet pills, Tops, etc), and/or dietician visits. Anthem also had their own form that the surgeon's office was to complete & submit. Along with the physician notes, I also sent copies of test results for proof of comorbidities (like sleeep apnea) and letters of neccesity from my pcp and specialists who were overseeing my comorbitites. When it comes down to it, regardless of what is required, the more you include, the better organized you have it, the quicker and more likely your approval will come (I had mine in sections..all the letters together with a cover/title page, all the journals together, etc...with a cover page at the very front explaining why I wanted the surgery).  Abit of an over-kill? Maybe. But it did show the insurance company that I was sincere and determined. And in order for WLS to work long term, you need those two characteristics. BTW...in January 2008, my Anthem policy will no longer cover hospitals, surgeries, ect at 100%. They are dropping it to 80%. Trust me, that would have killed me financially this past 6 weeks given all I've been through. The first two weeks at St. V's alone with most of it in ICU, Anthem paid $109,000! Good luck! And January will be here in no time at all! Sherri