I am in need of some help and advice!

I was denied earlier this month because I didn't meet the required 12 month doctor supervised diet. I have met all the other requirements, but that one. I have been on and off diets since I was in Junior High. And nothing has ever helped me keep it off. Is there anyone out there that got approved without having to go the 12 months on doctor supervised diet? My other problem is that even though I am 5'11" and weigh 377, I am healthy as can be. I have no true health problems. I have some joint and back pain from time to time, but nothing major. Not that I want anything to be wrong with me, but I think this could be hurting my chances of getting approved. All I know is that I don't have the money to follow the 12 month supervised diet and then turn around and have the surgery. I guess I'm just really upset and I don't see why insurance companies have to make it so hard on those who are trying to get healthy. Thanks for letting me vent and any advice you can give! PS this is how it was put from the insurance company. A documented failure of twelve (12) continuous months of compliance with medically supervised non-surgical methods of weight reduction. Medical supervision must occur under an MD, DO, or an Advanced Practice Nurse or PA working under physician supervision (as required by licensure) within the previous 24 month period prior to the request. A medically supervised weight management program is expected to consist of: Nutritional therapy or medical nutrition therapy including a very low calorie diet (e.g., MediFast or OptiFast) unless contraindicated., Behavior modification or behavioral health interventions, Supervised increase in activity, Pharmacologic therapy (unless contraindicated), Maintenance support to continue to encourage nutrition choices to reduce health risk factors and maintain a healthy lifestyle.

I did get around this requirement, but in my case, they used it to deny me altogether because the plan and coverage ended in the meantime. But I was able to convince a hearing judge that it was not medically necessary to do the dieting. However, it took a while, so you might want to start on the dieting anyway. But if you want my information, I would be happy to mail it to you if you can give me a mailing address. Good luck to you.

What you need basically is to get your doc to say he put you on a specific diet like Atkins or sugar busters and have him document it and go in and weigh every month. If you do that for twelve months they cant deny you. It should only cost an office call once a month. If you can get your doc to do this document anyway that would help. Some doc will some wont, At the worst you could have wls in one year. It would help if your blood pressure was a little high or you were pre diabetic. If your doc could say that or say the weight is giving you bad arthritus that would help too. A twelve month diet history is not uncommon. I was lucky my insurance did not require that and I got approved anyway. Keep doing whatever you have to do to get your surgery. DONT GIVE UP AND LET THE INSURANCE COMPANY WIN. They want to discourage you so you give up and they save money. Dont let them win.

Where they end up costing you a lot of money is on the requirements for behavioral and exercise therapy. When I approached my doctor with this, he said they had that type of program through their medical group, but it would run about $400/month. I'm not sure that the way this requirement is worded that they would allow just the doctor visits, but I would check to be sure that is acceptable before you do it, so they don't come back and want 12 more months.

Kelly, A friend of mine did manage to get around her supervised diet. Well, not really...she had the same PCP for several years that knew of her struggle to lose weight. Her doctor wrote a letter and outlined weights at visits and knowledge of diets she had tried....like weigh****chers, atkins, south beath...yada, yada, yada...the list could go on and on. Maybe this is an option for you......... Good luck with your WLS journey and you picked a great surgeon!! -Kelli

Kelly, I did get around my ins requiremnts for this simply by typing out in DETAIL my whole life history of dieting, with dates, amounts I weighed at beginning and ends of said diets, names of diets, etc.....Typed out htis was 1 entire page FULL. Beginning with Jr HIGH. My pcp also sent a brief letter about my struggles although she had only seen me one time! I think it IS possible. Just keep trying and hopfully one day your request for approval will end up on the desk of a sympathetic person. I truly think that is how some of us get approved so quick! Not fair though I know. SO I advise you to submit AGAIN with all your info typed out as to your life long dieting struggles and in the meantime do begin a supervised diet....so if the next letter doesn't work you've not wasted anymore time meeting their requirements. Good luck, Tami

Hello Kelly, I also have been denied for the same reason. My insurance wants the same documentation. I have complied a list of information about my health issues and have submitted it to them. It is very frustrating since I am now Home Bound and can't get out of the house with out assistance. I need hip surgery and the arthritus has gotten worst. Don't Give up!!! Write to them. Don't stop, I am not!! Keep on them. RoseH.