-------------Weight Loss Meetings---help
Hi Everybody,
I have to do my 6 month Dr. supervised diet AGAIN because I got denied from Medicaid and this time also weight loss program like Weigh****chers, I looked at their web site and was just wondering if there are any other programs here in North Carolina?
Also, does anyone know if I only have to attend once a month like I go to the Dr? Cause I was thinking of going once a wee****il I seen that I have to pay, lol, I am on a tight budget.
I will check with my surgeon but I followed their advice and got denied already so I am asking everyone
Thanks for any help
Tracey
Hi Tracey,
I have medicare and did have to do a supervised weight loss program, but didn't have to go to weigh****chers. I imagine if WW requires weekly attendance, then that's what you'll need to do to satisfy their requirements. I went to my Dr's office on a monthly basis and made sure that when I went that we discussed what my dietary and nutrional plan was going to be for the month, what my exercise regimen was for the month and what I was doing to ensure some behavior modification. It would be good to be sure that all of these components are in the next 6 month weight loss program you do. You will need to have your vitals... height, weight, BP, etc... taken at each appoint. You will also need to address what you are doing for weight loss, exercise and behavior modification. That could be weightloss/nutrition and behavior modication are being taken care of by attending weekly WW meetings and accessing their online forum and attending a monthly support group meeting. And then address your exercise regimen. ie., using a pedometer and walking 30 mins a day to ensure that you are getting at least 10K steps a day and going to Curves 3 times a week for cardio/strength circuit training. Doing something where an independent 3rd party documents your active participation goes a long way. You don't have to make incredible progress, but you do have be making an effort.
Wishing you all the best,
Barbara
ObesityHelp Coach and Support Group Leader
http://www.obesityhelp.com/group/bcumbo_group/
High-264, Current-148, Goal-145
Thank You Barbara,
This time around I am gonna make sure they document everything and I will check it before I leave the office too, lol. The medicaid reviewer didnt say if i go to WW monthly or weekly and I didnt think to ask. They expect great detail from us and then deny but are so vague when they tell you what they want. Oh well, I will be an expert when this is all over and can pass on information to help others like you have done, Thank you so much
Hi Tracy,
I did WW before my surgery not that UNC required it but I started my weight loss journey through Duke and they did require that I was at the same weight when I started thier program.
Long story short I had my surgery at UNC.
As for WW I think they have a great program and lots of suporrt.
Good luck to you.
Annie
I did WW before my surgery not that UNC required it but I started my weight loss journey through Duke and they did require that I was at the same weight when I started thier program.
Long story short I had my surgery at UNC.
As for WW I think they have a great program and lots of suporrt.
Good luck to you.
Annie
Hi Annie,
I was just so set on the surgery and learning how to eat after that and now I have to change gears its just taking a while for me to get it in my head, lol. I am kinda looking forward to the WW now and I did see that I need to go weekly. And I am afraid they will discourage me from having the surgery and I dont want that cause sometimes I am easy to mislead. Does sound like a good program and I might actually lose weight
Thank You Tracey
I was just so set on the surgery and learning how to eat after that and now I have to change gears its just taking a while for me to get it in my head, lol. I am kinda looking forward to the WW now and I did see that I need to go weekly. And I am afraid they will discourage me from having the surgery and I dont want that cause sometimes I am easy to mislead. Does sound like a good program and I might actually lose weight
Thank You Tracey
Hi Tracey,
You stand your ground about having wls you have made the choice.
When I went to WW I told them I was preparing for wls.
I thought maybe I could go back to WW after my surgery but I really dont see how I could possibly eat all that need on thier program now since my RNY.
I do find that even now it helps me record my daily intake.
I loved the points program that WW has and I think I have read they even have a newer program.
Keep me posted I am a lover of WW.
Annie
You stand your ground about having wls you have made the choice.
When I went to WW I told them I was preparing for wls.
I thought maybe I could go back to WW after my surgery but I really dont see how I could possibly eat all that need on thier program now since my RNY.
I do find that even now it helps me record my daily intake.
I loved the points program that WW has and I think I have read they even have a newer program.
Keep me posted I am a lover of WW.
Annie
Hi there. I got my RNY 11/12/08 and for me, I had no issues getting approval from Medicaid. However, I was checking off things directly from their requirements.
The Medicaid requirements were changed last year (they were not posted to the web until 9/1/08 but were in effect 7/1/08)
I do not read on the new requirements anything about forcing you to do WW, but there are some nutritionist requirements.
d. Medical record documentation substantiates all of the following information:
1. The recipient has attempted weight loss in the past without successful long-term weight reduction.
2. The recipient has met either criterion (a) or criterion (b) below:
(a) Physician-supervised nutrition and exercise program: The recipient has participated in physician-supervised nutrition and exercise program (including dietician consultation, low-calorie diet, increased physical activity, and behavioral modification), documented in the medical record. This physician-supervised nutrition and exercise program must meet all of the following criteria:
(1) Nutrition and exercise program must be supervised and monitored by a physician working in cooperation with dieticians and/or nutritionists; and
(2) Nutrition and exercise program(s) must be for a cumulative total of 6 months or longer in duration and occur within 2 years prior to surgery, with participation in one program of at least 3 consecutive months; and
(3) Recipient’s participation in a physician-supervised nutrition and exercise program must be documented in the medical record by an attending physician who supervised the recipient’s participation. The nutrition and exercise program may be administered as part of the surgical preparative regimen, and participation in the nutrition and exercise program may be supervised by the surgeon who will perform the surgery or by some other physician.
Note: A physician’s summary letter is not sufficient documentation. Documentation should include medical records of physician’s contemporaneous assessment of patient’s progress throughout the course of the nutrition and exercise program. For recipients who participate in a physician-administered nutrition and exercise program (such as MediFast or OptiFast), program records documenting the recipient’s participation and progress may substitute for physician medical records;
or
(b) Multidisciplinary surgical preparatory regimen: Proximate to the time of surgery, the recipient must participate in an organized multidisciplinary surgical preparatory regimen of at least 3 months’ duration, meeting all of the following criteria, in order to improve surgical outcomes, reduce the potential for surgical complications, and establish the recipient’s ability to comply with postoperative medical care and dietary restrictions:
(1) Consultation with a dietician or nutritionist; and
(2) Reduced-calorie diet program supervised by dietician or nutritionist; and
(3) Exercise regimen (unless contraindicated) to improve pulmonary reserve prior to surgery, supervised by exercise therapist or other qualified professional; and
(4) Behavior modification program supervised by qualified professional; and
(5) Documentation in the medical record that the recipient has satisfactorily complied with the multidisciplinary surgical preparation regimen.
Note: A physician’s summary letter, without evidence of contemporaneous oversight, is not sufficient documentation. Documentation should include medical records of the physician’s initial assessment of the recipient, and the physician’s assessment of the recipient’s progress at the completion of the multidisciplinary surgery preparation.
Note: These medical record entries must indicate individualized intervention (prewritten entries to which only the date, recipient’s name, and vital signs are entered do not document the specific interaction that occurred on that date).
and
e. The recipient has no correctable cause for the obesity, such as an endocrine disorder.
and
f. There is medical record documentation of a psychological evaluation assessing the recipient’s suitability for surgery and his or her ability to comply with lifelong dietary changes and medical follow-up. Components of such an assessment should include
1. levels of depression due to increased risk of suicide
2. eating behaviors
3. substance abuse evaluation
4. stress management
5. cognitive abilities
6. social functioning
7. self-esteem
8. personality factors or other mental health diagnoses that may affect treatment
9. readiness and ability to adhere to required lifestyle modifications
10. follow up/social support
Note: Providers should consider after-care follow up if issues are identified.
and
g. The surgery is one of the following procedures:
1. gastric bypass with roux limb 150 cm or less (roux-en-Y) (CPT code 43846 or 43644), or
2. adjustable gastric banding, for recipients with a BMI of less than 50 (the open gastric banding is covered only when complications occur during the
laparoscopic attempt) Recipients with a BMI greater than or equal to 50 will be considered on a case by case basis when information is provided as to the necessity of this procedure for the specific recipient (CPT code 43770 or 43999); or
3. biliopancreatic diversion with or without duodenal switch, for the most severely obese recipients (typically with a BMI greater than or equal to 50), to be considered on an individual basis with appropriate documentation of the indications for this procedure under current standards of care (CPT code 43659, 43845, or 43999); or
4. gastric bypass, with small intestine reconstruction to limit absorption, with roux limb greater than 150 cm (long-limb roux-en-Y) for recipients with a BMI greater than or equal to 50, to be considered on an individual basis (CPT code 43847 or 43645).
5. vertical-banded gastroplasty (CPT code 43842 or 43659), to be considered only for those recipients who are at increased risk of adverse consequences of a roux-en-Y gastric bypass due to the presence of any of the following co-morbid medical conditions:
(a) inflammatory bowel disease (Crohns disease or ulcerative colitis); or
(b) radiation enteritis; or
(c) hepatic cirrhosis; or
(d) demonstrated complications from extensive adhesions involving the intestines from prior major abdominal surgery, multiple minor surgeries, or major trauma; or
(e) poorly controlled systemic disease with documented evidence of rapidly progressive morbidity or impending mortality.
I would recommend you go to: www.ncdhhs.gov/dma/physician/1a15.pdf and print out the information which is direct from NCDHHS and their policy and rules to ensure a smooth approval.
The Medicaid requirements were changed last year (they were not posted to the web until 9/1/08 but were in effect 7/1/08)
I do not read on the new requirements anything about forcing you to do WW, but there are some nutritionist requirements.
d. Medical record documentation substantiates all of the following information:
1. The recipient has attempted weight loss in the past without successful long-term weight reduction.
2. The recipient has met either criterion (a) or criterion (b) below:
(a) Physician-supervised nutrition and exercise program: The recipient has participated in physician-supervised nutrition and exercise program (including dietician consultation, low-calorie diet, increased physical activity, and behavioral modification), documented in the medical record. This physician-supervised nutrition and exercise program must meet all of the following criteria:
(1) Nutrition and exercise program must be supervised and monitored by a physician working in cooperation with dieticians and/or nutritionists; and
(2) Nutrition and exercise program(s) must be for a cumulative total of 6 months or longer in duration and occur within 2 years prior to surgery, with participation in one program of at least 3 consecutive months; and
(3) Recipient’s participation in a physician-supervised nutrition and exercise program must be documented in the medical record by an attending physician who supervised the recipient’s participation. The nutrition and exercise program may be administered as part of the surgical preparative regimen, and participation in the nutrition and exercise program may be supervised by the surgeon who will perform the surgery or by some other physician.
Note: A physician’s summary letter is not sufficient documentation. Documentation should include medical records of physician’s contemporaneous assessment of patient’s progress throughout the course of the nutrition and exercise program. For recipients who participate in a physician-administered nutrition and exercise program (such as MediFast or OptiFast), program records documenting the recipient’s participation and progress may substitute for physician medical records;
or
(b) Multidisciplinary surgical preparatory regimen: Proximate to the time of surgery, the recipient must participate in an organized multidisciplinary surgical preparatory regimen of at least 3 months’ duration, meeting all of the following criteria, in order to improve surgical outcomes, reduce the potential for surgical complications, and establish the recipient’s ability to comply with postoperative medical care and dietary restrictions:
(1) Consultation with a dietician or nutritionist; and
(2) Reduced-calorie diet program supervised by dietician or nutritionist; and
(3) Exercise regimen (unless contraindicated) to improve pulmonary reserve prior to surgery, supervised by exercise therapist or other qualified professional; and
(4) Behavior modification program supervised by qualified professional; and
(5) Documentation in the medical record that the recipient has satisfactorily complied with the multidisciplinary surgical preparation regimen.
Note: A physician’s summary letter, without evidence of contemporaneous oversight, is not sufficient documentation. Documentation should include medical records of the physician’s initial assessment of the recipient, and the physician’s assessment of the recipient’s progress at the completion of the multidisciplinary surgery preparation.
Note: These medical record entries must indicate individualized intervention (prewritten entries to which only the date, recipient’s name, and vital signs are entered do not document the specific interaction that occurred on that date).
and
e. The recipient has no correctable cause for the obesity, such as an endocrine disorder.
and
f. There is medical record documentation of a psychological evaluation assessing the recipient’s suitability for surgery and his or her ability to comply with lifelong dietary changes and medical follow-up. Components of such an assessment should include
1. levels of depression due to increased risk of suicide
2. eating behaviors
3. substance abuse evaluation
4. stress management
5. cognitive abilities
6. social functioning
7. self-esteem
8. personality factors or other mental health diagnoses that may affect treatment
9. readiness and ability to adhere to required lifestyle modifications
10. follow up/social support
Note: Providers should consider after-care follow up if issues are identified.
and
g. The surgery is one of the following procedures:
1. gastric bypass with roux limb 150 cm or less (roux-en-Y) (CPT code 43846 or 43644), or
2. adjustable gastric banding, for recipients with a BMI of less than 50 (the open gastric banding is covered only when complications occur during the
laparoscopic attempt) Recipients with a BMI greater than or equal to 50 will be considered on a case by case basis when information is provided as to the necessity of this procedure for the specific recipient (CPT code 43770 or 43999); or
3. biliopancreatic diversion with or without duodenal switch, for the most severely obese recipients (typically with a BMI greater than or equal to 50), to be considered on an individual basis with appropriate documentation of the indications for this procedure under current standards of care (CPT code 43659, 43845, or 43999); or
4. gastric bypass, with small intestine reconstruction to limit absorption, with roux limb greater than 150 cm (long-limb roux-en-Y) for recipients with a BMI greater than or equal to 50, to be considered on an individual basis (CPT code 43847 or 43645).
5. vertical-banded gastroplasty (CPT code 43842 or 43659), to be considered only for those recipients who are at increased risk of adverse consequences of a roux-en-Y gastric bypass due to the presence of any of the following co-morbid medical conditions:
(a) inflammatory bowel disease (Crohns disease or ulcerative colitis); or
(b) radiation enteritis; or
(c) hepatic cirrhosis; or
(d) demonstrated complications from extensive adhesions involving the intestines from prior major abdominal surgery, multiple minor surgeries, or major trauma; or
(e) poorly controlled systemic disease with documented evidence of rapidly progressive morbidity or impending mortality.
I would recommend you go to: www.ncdhhs.gov/dma/physician/1a15.pdf and print out the information which is direct from NCDHHS and their policy and rules to ensure a smooth approval.
Hi Monica,
Thank you for the information, I looked at the Medicaid site when I first started and then kinda thought the Drs. and insurance specialist that I have to pay $500 for their help would do things right lol. I now see that they did add some changes and I was in the process of finishing my 6 Dr. visits and had to have some other tests that took some time so I didnt submit to insurance for a while and I wasnt told of the changes and I guess the surgons office didnt know either, so I will just be very thorough this time and make sure I get it right.
Also the review woman didnt seem very educated about the process when I asked questions I could hear her fliping thru pages (confrence call). She is the one who said I have to do WW so I am gonna have to check on that cause your right it does not say that. She was being so particular with me they should be more clear in the guidlines.
Thank you for your help and your little girls are like Angels !!!!!
Thank you for the information, I looked at the Medicaid site when I first started and then kinda thought the Drs. and insurance specialist that I have to pay $500 for their help would do things right lol. I now see that they did add some changes and I was in the process of finishing my 6 Dr. visits and had to have some other tests that took some time so I didnt submit to insurance for a while and I wasnt told of the changes and I guess the surgons office didnt know either, so I will just be very thorough this time and make sure I get it right.
Also the review woman didnt seem very educated about the process when I asked questions I could hear her fliping thru pages (confrence call). She is the one who said I have to do WW so I am gonna have to check on that cause your right it does not say that. She was being so particular with me they should be more clear in the guidlines.
Thank you for your help and your little girls are like Angels !!!!!
unfortunately, the surgeon's office cannot keep up with all the different policies and insurances. Most do not know that Medicaid now pays for the DS (and had there been more than one not too experienced DS surgeon in NC last fall (guess there is a new one at Duke but I haven't investigated since its too late now) I would have opted for the DS.
The biggest thing that my surgeon's office said at the seminar was that the patient needed to know the requirements. I wish yours had told you so you wouldn't be left the one hanging and waiting and re-doing things.
If you look on the back of your medicaid card they give you a number to call, or you can call: (919) 647-8170 or 1-888-245-0179. HOWEVER: they do not have all the information memorized for all the categories of coverage either. They were great when I called checking to see if they had received my packet and checking to see if approved. I would recommend you ask for them to read it over with you and disect it. Medicaid will not require you do any formal diet program which would cost money (i.e. Weigh****chers, Jenny Craig, Nutrasystem).
They do not yet cover nutritionist visits (as far as I have been able to find -- unless you are pregnant or under the age 21).
The requirements are that you speak with a nutritionist and do 6 mmonths of physician supervised diet, this would be going to see your PCP once a month for 6 months and discussing the changes you have implemented along with his/her ideas. Smaller portions, low cal, low carb, walking/exercise routines.
If your surgeon requires a nutritionist visit I would do that during my 6month diet so it can be counted as part of your Medicaid requirements. (that is exactly how I did it).
MAKE SURE that you do not talk about anything but your diet/exercise program with your PCP during this visit. Make sure your PCP documents the discussion of diet and exercise, ask for suggestions so he will have to write them in his notes as well. Ask him to recommend a caloric intake, whether lo carb or lo cal, or any diet/exercise related question each visit. Even ask them to review the Medicaid requirements so that they know what is expected from them as well (I have a WLS friendly PCP so she was more than happy to ensure that there were no issues)
If you need any help, need a resource, need a number or just someone to listen to you complain about how one hand doesn't know how to communicate with the other hand just PM me and I will send you my phone number. This process really isn't as tough as some people (insurance specialists at surgeon's offices) make it out to be. I decided in February to go ahead and start the process, started my 6mo diet in March, went to seminar in June, scheduled my own specialist clearances, saw the surgeon's nutritionist and by the beginning of September my paperwork was being sent to Medicaid for Approval. Medicaid received my information on Monday and approved me on Tuesday. 8months from I am going to do it to approval, and then surgery on 11/12. And 3 months later I am down 69.4lbs halfway to goal, the wait will be worth it even if it doesn't seem like it is now.
The biggest thing that my surgeon's office said at the seminar was that the patient needed to know the requirements. I wish yours had told you so you wouldn't be left the one hanging and waiting and re-doing things.
If you look on the back of your medicaid card they give you a number to call, or you can call: (919) 647-8170 or 1-888-245-0179. HOWEVER: they do not have all the information memorized for all the categories of coverage either. They were great when I called checking to see if they had received my packet and checking to see if approved. I would recommend you ask for them to read it over with you and disect it. Medicaid will not require you do any formal diet program which would cost money (i.e. Weigh****chers, Jenny Craig, Nutrasystem).
They do not yet cover nutritionist visits (as far as I have been able to find -- unless you are pregnant or under the age 21).
The requirements are that you speak with a nutritionist and do 6 mmonths of physician supervised diet, this would be going to see your PCP once a month for 6 months and discussing the changes you have implemented along with his/her ideas. Smaller portions, low cal, low carb, walking/exercise routines.
If your surgeon requires a nutritionist visit I would do that during my 6month diet so it can be counted as part of your Medicaid requirements. (that is exactly how I did it).
MAKE SURE that you do not talk about anything but your diet/exercise program with your PCP during this visit. Make sure your PCP documents the discussion of diet and exercise, ask for suggestions so he will have to write them in his notes as well. Ask him to recommend a caloric intake, whether lo carb or lo cal, or any diet/exercise related question each visit. Even ask them to review the Medicaid requirements so that they know what is expected from them as well (I have a WLS friendly PCP so she was more than happy to ensure that there were no issues)
If you need any help, need a resource, need a number or just someone to listen to you complain about how one hand doesn't know how to communicate with the other hand just PM me and I will send you my phone number. This process really isn't as tough as some people (insurance specialists at surgeon's offices) make it out to be. I decided in February to go ahead and start the process, started my 6mo diet in March, went to seminar in June, scheduled my own specialist clearances, saw the surgeon's nutritionist and by the beginning of September my paperwork was being sent to Medicaid for Approval. Medicaid received my information on Monday and approved me on Tuesday. 8months from I am going to do it to approval, and then surgery on 11/12. And 3 months later I am down 69.4lbs halfway to goal, the wait will be worth it even if it doesn't seem like it is now.
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