6-month diet/exercise plan - CareFirst

Hi all,
I just spoke with my primary care doc about setting up a 6-month diet/exercise program. He's having me weight myself daily, take blood pressure at home, and see a nutritionist, and we'll meet every month. He wants me to do 45 minutes of elliptical 3 x a week in the gym, which will be a challenge to fit in, since I already hike with the dog for at least that long 3 or 4 days a week, and it seems just as aerobic. I think I will buy a heart rate monitor to compare. I'm an active person compared to most Americans.

If you have experience with what insurance companies like to see regarding the 6-month plan, please chime in (documentation from doctor, nutritionist, therapist, my own journal, etc.). My PC Dr. is a little concerned that with a 38-39 BMI, they might think I'm not heavy enough, even though I have 7 co-morbidities (incl. sleep apnea and high BP/cholesterol). 

What do they really want to see with the diet plan? That you're unsuccessful at losing weight through diet? I'm sure I could lose 20 pounds in the short-term, but I would gain it back. I already eat healthful food (fish, veggies, fruit, whole grains, nuts), but I have an eating disorder, which is why I'm overweight.

I have CareFirst of the National Capital Area (D.C. and MD) PPO. I have a consultation with Dr. Schweitzer at Hopkins on Nov. 3 for VSG.

Thanks!

Hi there!  I know with my doctor, I HAD to lose a certain amount of weight before he would even operate on me.  The insurance company is looking for official documentation that you have been actively participating in a diet/exercise program for 6 consecutive months.  Those can range from official reports to dietician notes recording each visit, etc.  If all the people you are seeing is documenting your visits then by the end of your 6 months, you will need all that documentation to give to your surgeon so his office can put it into the package to send to the insurance comapny for approval.  With your co-morbities, you should qualify because I believe the NIH standard is at least 2 co-morbities if your BMI is 30 - 40.  Double check with your insurance company.  I used to have care first and I know they have a wealth of information on their website regarding the gastric bypass.  Use their search engine for their published articles on their standing with the procedure. 

I hope this helps!

I have carefirst and this is what their web site says is their policy for weight loss surgery.

This policy statement relates only to the services or supplies described herein. Coverage will vary from contract to contract and by line of business and should be verified before applying the terms of the policy.

Serving Maryland, Delaware, the District of Columbia and portions of Virginia. CareFirst of Maryland, Inc., Blue Cross Blue Shield of Delaware, Group Hospitalization and Medical Services, Inc., and CareFirst BlueChoice, Inc. are independent licensees of the Blue Cross and Blue Shield Association. ® Registered trademark of the Blue Cross and Blue Shield Association. ®' Registered trademark of CareFirst of Maryland, Inc.

 

Unfortunately, Care First is not the problem, it's my company's written exclusion in their contract with Care First. I don't think Maryland's obesity law covers written exclusions, but if anyone knows otherwise, please let me know!

Are you saying that EVEN WITH AN EXCLUSION you can get your insurance to pay????  I've never heard of this before.....how?????

Not at all. However, my company's HR department was certain they covered WLS and they were shocked to find out there is a written exclusion in the contract. So now they're looking into if and how they can add a rider to the contract with Care First to include WLS, but I have no idea if it will fly or not.

My company is under the 150 employee in the US, so the WLS are exclused. They looked in to adding to the plan and found out that they would have to make the quota of 150 before it could be added. My Dr. told me that if its excluded, Slim chance in h!!! that it would be covered.
My pcp is ordering as many test as posible before she sends my to see the surgeon. to cut costs.

 Well, we have over 350 here, so it shouldn't be too hard to add.

let's try that again...

Obesity is an increase in body weight due to an excessive amount of body fat.

Morbid obesity is also referred to as medically complicated obesity. According to the National Institutes of Health (NIH) Consensus Conference Panel, patients who have serious morbidity directly related to their weight are considered morbidly obese. Some examples of co-morbidities include hypertension, diabetes mellitus or cardiopulmonary conditions. Patients with morbid obesity generally have at least a body mass index* (BMI) of 40 (35 with certain co-morbid conditions).

* BMI = [weight (kilograms) / height (meters) squared]

The goal of bariatric surgery for the treatment of morbid obesity is to restrict stomach capacity, encourage malabsorption or both. Several surgical open and / or laparoscopic procedures have been proposed, including:

• Gastric bypass, in which approximately 90% of the stomach is bypassed and anastomosed (reattached) to the proximal jejunum during an open or laparoscopic procedure. The unused portion of the stomach and intestine is also anastamosed to the jejunum or ileum, via a Roux-en-Y surgical technique. A length of the small intestine may also be bypassed, depending on the procedure (e.g., long or very long Roux-en-Y gastric bypass). NOTE: The Roux-en-Y technique is also used for other gastrointestinal surgeries, unrelated to surgery for morbid obesity.
• Gastric stapling (or vertical banded gastroplasty), in which a proximal pouch of 30-60 ml and a one centimeter outlet is created by a vertical row of staples and horizontally placed reinforcing band. This is not the same as gastric banding.
• Jejunoileal bypass, any surgical procedure that shunts ingested food from the jejunum into the ileum, thus bypassing a majority of the small intestine.
• Biliopancreatic bypass (i.e. Scopinaro procedure), a surgical procedure involving a subtotal gastrectomy to limit food ingestion and a small intestine bypass to divert bile and pancreatic juice into the distal ileum.
• Duodenal switch, is a modification of the biliopancreatic bypass.
• Sleeve gastrectomy, removal of the fundus portion of the stomach to limit food intake which is performed as part of the biliopancreatic bypass and duodenal switch techniques.
• Gastric wrapping, a surgical procedure in which the stomach is folded over on itself and a full stomach wrap of polypropylene mesh is applied, used to limit gastric volume.
• Adjustable gastric banding, a surgical procedure which limits food intake by placing a constricting ring around the stomach's top end (fundus). The adjustable gastric band is a surgical device that is laparoscopically applied around the stomach, creating a small gastric pouch, and a calibrated opening to the rest of the stomach.
• Gastric balloon (e.g. Garren-Edwards gastric bubble), is an inflatable device placed in the stomach under endoscopic guidance in an attempt to decrease gastric capacity. The device is then filled with normal saline in an attempt to induce early satiety
• Transoral gastroplasty (e.g. StomaphyX^TM), is an endoscopic procedure that restricts stomach capacity by creating plications (folds of tissue) in the stomach wall. Transoral gastroplasty is intended primarily for patients who have already undergone bariatric surgery who have regained weight or whose weight loss is unsatisfactory.

Provider Guidelines Provider Guidelines

The following guidelines are recommended for patients undergoing surgical treatment of morbid obesity:

• preoperative evaluation for potentially undiagnosed comorbidities should be performed as appropriate
• prophylactic treatment for deep vein thrombosis if clinically indicated

Documentation that a patient has completed a structured diet program can be provided by any of the following: physician notes, notes of health care providers other than physicians, receipts of payment for a structured diet program, or diet or weight loss logs from a structured diet program.

Preauthorization of the surgical treatment of morbid obesity is strongly encouraged.

NOTE: Check individual contract for specific preauthorization requirements.

 

Hey There, 

Assuming that you are speaking of Carefirst Blue Cross Blue Shield.  If so, just wanted to let you know that Dr. S doesn't take BC/BS and you will be paying his fees out of pocket.  Hospital and all that goes with it might be covered, just not his fees.  Look into it.  Good luck!!  C