Can someone interpret this for me?

Ok , what would YOU interpret this as?

Bariatric surgery will be covered under the following conditions:

1- The member has participated in a physician supervised multidisciplinary weight loss program for chronically obese members whos lives are endangered due to excessive weight without success. A multidisciplinary weight loss program includes
- Nutritional counseling
- Exercise instruction
- behavior modification components

2- Failed medical therepy. The initial goal of such medical therapy is to reduce the body weight by approcimately 10% of baseline weight. If at lease 5% reduction from baseline is achieved within at least 6 months of therapy, further weight loss attempts by surgery may be attempted.


Ok....what is the difference?  I was under a medically supervised 6 month diet. I didnt lose 5% of my initial weight....Does that mean they'll only do the surgery if you can lose 5-10% of your initial body weight? Can someone explain?

Sorry I can't explain that. I just wanted to say I am sorry you have having problems with approval. It can drive you crazy. I am still pre-op, and I thought I would be getting my surgery two months ago but I had to jump through some more hoops. Hang in there, you will get to the end of the rainbow so to speak.

I saw that the insurance companies write things like that so we get confused - think that we aren't covered and move on! I would call the insurance company or your surgeon's office tomorrow and ask them to tell you what the policy is.

Best of luck with it!

Liz

PS if you don't get an answer you are comfortable with, call back and talk to someone different, they all interpret it differently too!

Did you cut and paste this from somewhere?  Or, did you copy it? The reason I am asking is because I want to know if there is an  "AND" between #1 and  #2.  I work for Aetna and if there is an  OR, we would cover you after completing the 6 month program.  If there is an AND, you would need to meet both requirements.  

Definitely call the insurance company and the insurance clerk at your surgeon's office to assist with interpretation.   If you would like me to try to interpret it better, send me the link to your insurance company's site where you found this and I'll do my best to help.

Best of luck, I know how difficult it can be.  I am actually still waiting on my official approval, so I feel your pain!

There isnt an "and" or "or", it's simply a list. Here is the link www.upmchealthplan.com/online/pdf/Policy_Procedures/MP.040%2 0Surg%20Proced%20for%20Morbid%20Obesity%20Ver%20Oct%2007.pdf

I'm going to call the insurance coordinater at the hospital to ask her if she knows anything about it before I call the insurance company.
Thank you for looking into this for me! (hugs)

I have Aetna insurance and had to go thru Step #1 in order for my surgery to be covered - it was a 3 month time period. I had to find a nutritionist (not one from Barix were I was having my surgery) - I joined a fitness center and hired a personal trainer. The insurance did count the nutritionist as the behavior modification portion as well. I also checked in with my family doctor at least once a month, and I had to provide Aetna with a 5 year weight history to show that I was obese for at least 5 years (gee, that was a no-brainer!).

But if you're still confused call and talk to someone and make sure that person is clear on what you're asking and can give you clear, concise answers.

I know its frustrating and confusing, but if your work with them they will work with you and you will get through this. Just by seeing the nutritionist and working out I lost 33 lbs, and the nut didn't put me on a strict diet or anything, so it does work, plus it prepares you for life after WLS.

Best of luck to you - you're going to be fine.

Kathy

well, I've looked and have some interpretation for you. On page 4 under specific indications, it says: "when all of the following criteria are met"    

so that answers my question about the AND or OR.  You need to meet ALL of the criteria that they have listed, including:

  Failed efforts at medical therapy. The initial goal of such medical therapy is to reduce body weight by approximately 10% of baseline weight. If at least a 5% reduction from baseline is achieved within at least 6 months of therapy further weight loss attempts by surgery may be attempted,

So, unfortunately, you are going to have to lose at least 5% of your baseline weight within the 6 month period.  I say just keep doing what you are doing.. try the liquid diets that have been suggested to you on the other thread.  I don't know how much you weighed to start with, but if you weighed 250, then you will need to lose 13 pounds.  I know it is hard, but you CAN DO IT!!     It will be so worth it in the end.    

Still call your insurance coordinator and the insurance company to be sure I am understanding it correctly, but I am pretty sure that I got the jist of it. 

Good luck!

There should be a law that insurance companies have to CLEARLY state their approval criteria.  I was wondering if I could fall below the minimum 35 BMI during my 6 mo. (I'm 3 mo. in and 4 pounds above the min.) and was told by the insurance expert at my surgeon's office 'If you fall below the 35 BMI then you wouldn't need surgery, would you." (translation- don't lose too much).  There are no percentages or specifications with my insurance for this diet.  It's like playing a game you don't have the rules to.  Hope I guessed the rules right or I'm in for a denial!

Good luck...you CAN lose the weight, just remember how badly you want this!!!

I asked my WLS about the consequences of losing weight pre-surgery to where my BMI drops below the requirement for surgery.  He (and the others in the office) told me that it wouldn't matter.  They told me that it only mattered what my BMI was on my first visit to the WLS.

Hopefully this is accurate, because I'll be in trouble if it's not.  I'm not panicing though, they seem to know what they are doing and I've only heard good things about the Dr & the practice.  I'm trusting them, and trusting in God!

Good luck on getting that authorization!
Pat