12-month dieting requirement

Hello there!  I am new to the site and have recently begun my pursuit of WLS.  Today I spoke to my insurance (BCN of Michigan HMO) and found out the requirements for obtaining approval, one of which is 12 months of "supervised" dieting.  Like most of you I'm sure, I've been doing this diet thing for 10+ years - I've tried everything in the world and have always treated WLS as a last resort - but I am ready to make that decision and am discouaged at the thought of waiting a year to get this done... Having said that, does anyone know how strict this requirement is?  I have been seeing a psychologist since May for behavioral therapy concerning my weight and poor eating habits, could something like this count towards the 12 months?  I was following a plan from 11/05 - 2/06 (diet/exercise) but this was not supervised - could something like this count?   I am meeting with my PCP on Monday to discuss all of this, but would like to know some of your experiences with the 12 month dieting requirement and what exactly the insurance companies expect from this...  I understand they're all different, but I'm just looking for some idea. Thanks! Jennifer

Hi Jennifer: I have BCBS of Alabama and they require a 6-month supervised diet, but I know many of them now require a 12-month.  It is my understanding that they are quite strict about this.  This is what I did and the patient advocate at my surgeon's office said she thinks I should be approved as I have very good documentation.   I started a supervised diet with my PCP...I was doing weigh****chers, but you must see your PCP every month and they must weigh you and they must also document what diet you are using, and any behavioral modification, such as you seeing your psych and what exercise program you are on, or if you cannot participate in an exercise program due to some physical problem, they should document whey you cannot participate. They stated that you had to see a nutritionist for an evaluation, but I went a step further and saw the nutritionist monthly with weigh-ins also, just for back-up.   The PCP visits MUST be montly and MUST be consecutive...that is ....you can't have been on a 3 month diet one year and a 9 month diet the next and consider that the 12 months.  I have heard of some people using their weigh-ins at other places, like weigh****chers or a gym, if their PCP is willing to indicate that those weights appear valid and they agree with your weight at these times, but that is not the norm.  If you can somehow get hold of any documented weights during the time frame you are indicating and your PCP is willing to write a letter for you, you might be able to go with that.

Even if you are not sure if they will take this or not, you should start a supervised diet ASAP, because the research and obtaining all this information will take some time and you don't want to be wasting time thinking they will approve and then they do not come through.

Its great to talk to your insurance company over the phone, but I would make sure you get a hard copy of their policy on WLS and make sure you follow their prerequisites to a tee.  They have been known to change the policy during the 12 months and then you have a problem if you don't have a copy of the policy that was in place when you started the 12 month diet.

Hope this helps some.  Everything I have said may not apply to your particular insurance, but it should be fairly similar.

Thanks for your response Angela.  I made an appointment with my PCP for Monday to discuss all this with him and see where things stand and how he wants to proceed.  I am sooooo disappointed at the thought of spending another year like this, I totally broke down tonight.     I will go see him Monday and try to find some hope in what we decide to do...maybe I can lose some weight in the next 12 months...I've just been down this road so many times that the thought of permanantly losing weight on my own no longer seems possible.  I need to adjust my thinking a bit I guess. Thanks again for the info. Jennifer     

many people miss this.... and of course, it can vary depending on the company, and your specific policy.... SOME ins co. will waive (or at least reduce) the "supervised diet attempt" requirement if you can at least show a track record (your doctor/patient record) of sustained morbid obesity.... plus, if you have long standing (or even newly diagnosed) comorbidities, they may take that into consideration. many people don't think to ask about it. my DW's friend had RNY about a year and a half ago.  She had been MO (BMI 45-47) for at least 10-15 years, though otherwise in fairly decent health so she (and her doctor) just "lived with it, but kept an eye out" whenever she'd go in for a regular checkup (every 6 months) or if she went in due to illness (allergies, flu, etc) they would check her weight and make note in her chart (as all docs do when you go in for anything) about 6 months prior to her WLS, she was diagnosed with diabetes and something else (can't remember off hand)  because of her sustained MO (recorded periodically by her doc) and her newly diagnosed comorbidity, her ins co waived their usual 6-month supervised weight loss attempt. sorry, I don't know what her ins. co is... but it's something to check into. good luck.

Jennicolleen:

I'm so sorry if I made you feel badly...I sure didn't mean to....but I do think its best to know what you are up against....I know it disappointing....but after you get over the initial disappointment....then you need to get mad and make things happen.   I started my diet in January and finished in June, however I heard that they sometimes state that your first visit to you doctor was only a consult and you really have to go 7 months...so I did an extra 2 just in case....There is a lot of testing to be done anyhow....you will probably need a sleep study, blood work, etc, which take some time to get done.  The months went by fairly quickly, although I've only lost 26 pounds...that's better than nothing I guess.  I'm hoping that I get approval soon and pray I will surely have my surgery before November.  And believe me....I am one of the most impatient people in the world!! Do not be discouraged from trying to see if you can gather the information you might need in order to avoid the 12-month diet.  I know some people have done it.  I have even heard of some that documented their weight through pictures and were successful at getting their PCP's to write very good letters with the knformation needed and their assurance that they knew you were dieting and they were aware of your sucess or of your not being successfull with weight loss.  All of this can lean in your favor. Please do not give up....maybe you should stay away from nasty ole pessismists like me!   I wish you luck and please let me know if I can do anything for you,

Angela, my little "breakdown" wasn't because of your post!  Please don't think that.  After I submitted my post the other night I kept reading around on the site (I adore this site, so glad I found it) and could just see from all the information I found that there was a likelyhood that I will be waiting a year and it just kind of killed my spirit.  It wasn't you, and I'm sorry you thought that.  I thoroughly appreciated your comments as this was my first post and I was glad to have someone respond! I assume many of the people who are on this site at some point had decided they've tried everything and that they just couldn't take being heavy anymore and finally made the decision to move forward with WLS.  I was at that point...I've been aggressively fighting this since 2004 (dieting, gym membership, Weigh****chers, weekly therapy, etc. etc.), and off an on fighting it for 10 years.  I'm 29 and I want my life back NOW, not in a year!  So, my husband and I had a long talk last night about what to do and we are going today after work to buy ourselves bikes.  My pessimistic instinct is to think, "Oh this is just another pointless attempt" but I'm going to combat that thinking and try to take these 12 months seriously.  I will see my doc on Monday and go from there and maybe he can improve the timing, but if not, I'll just have to accept it.   I thank you sincerely for reading my post and taking the time to answer me.  It sounds like you're on your way and I hope things work out for you soon.  :-)

Jenni, I understand your frustration.  I finally decided to take the weight loss bull by the horns in May and went to my PCP.  He was very supportive and prescribed an 1800 calorie diet and 4000 steps/day of walking.  However, I called my insurance and despite diabetes, hypertension, gout, urinary incontinence, arthritis, etc, I have to complete a physician supervised diet and exercise program and they told me which program they would accept and there is only one.  The upside of this is they are paying most of the cost of the program, exercise physiologist, nutritionist, psychologist and gym membership.  It is coded as level 3 cardiac rehab because I have had a past history of congestive heart failure and that helps too.  I also am scared to death that they'll find some way to deny me after all this effort but I keep in close touch with the nurse at my insurance and let her know how hard I'm working.  So, that said, I'd be sure that your insurance doesn't want you to have some provable exercise program, not something you do on your own.  I tried to get mine to give me a written guideline but they basically refused, however, they are very nice on the phone and helpful.  They have one person who specializes in bariatric claims.  I also asked them if they had ever covered anyone's bariatric surgery, since my husband asked me if I knew their history.  They assured me they had although I don't know anyone personally.  I work at a University and we are basically self-insured but the surgery is not excluded, just only covered if medically necessary.  My PCP is optimistic and he says every month that he uses the words "motivated" and "compliant" because that is the kind of words they look for.  I also keep a food log and turn it in to him every month and he is including it and the exercise and weight records from the gym also.  My chart is fatter than I am!!!  I hope you can find a way to shorten your waiting time but if not use it to your advantage to get in as good physical condition as you can.  It will only make the surgery and recovery easier for you.  Hugs and good wishes to you. Lana

I might not be an expert in this area, but I'll tell you what the answer was when this was asked at my hospital of choice. "A doctor is a doctor."  So if you've been on a plan with your psychologist, then that counts as a doctor.   Definitely check in the details of what your insurance requires (ie: do you have to visit every single month? or just when  you start and stop? Does it have to be your PCP or can it be any doctor?)   Hope that helps, Pam

The diet can be overcome if you show that you have tried and failed other diets.  They do relax the rules depending on the amount of proof you have, and I do know that BCBS in some states has reduced to 6 months there diet period.  What you need to do is appeal, and at the same time follow the diet.  This way, if you lose you'll be about finished with the diet.  And if you win, then you don't need to finish the diet out.

Hi everyone I am just sitting here bawling my eyes out trying to read these posts tonight.  I'm not sure if it's due to the fact I feel so alone right now with not much battle left in me to bother fighting them...or encouraged because I see I'm not alone, but still yet so discouraged.  I too just found out today that I was denied for WLS.  It is covered under my insurance if medically necessary.  I would really just love to know how they feel someone who has been over 40 BMI since at LEAST high school..is now 33 and sickingly over 60 BMI does not meet a medical necessity.  Do they really think we just sit around until we can't wipe ourselves as needed anymore..or properly give ourselves a shower..can't walk to the mailbox without feeling like we can't catch our breath...and then say hmmmm..maybe I should go have surgery to do something about this?  NO...we have TRIED AND TRIED AND TRIED until we don't have an ounce of faith left in ourselves and ready to just succumb to the idea we're just "stuck" like this.  Strict 6-month diet protocol required before they will consider it.  Yeah thanks...I've spent countless years already feeling like a failure..let's stretch it out a little longer.   I'm sorry, I know my post is very discouraging...very bleak..but right now that's how I feel.  I tried as hard as I could not to get my hopes up before hearing back from the insurance company, but even despite my efforts..I guess I did, because I'm just really devastated right now.  I didn't come to the decision of having surgery overnight...it was a long process in which I excused myself out of many times with every excuse I could come up with for no other reason than being scared..feeling ashamed I was taking the "easy" way out.  I talked to Liv-Lite and read their papers they sent.....I had never heard anyone explain why it's so hard for someone of this size to achieve the goals they would like without surgery...I started feeling better about the decision.  I was so excited when I started the paperwork that I even retrieved my med recs from 2 different states by myself before they had the chance to send the records requests.  Now....the brick wall.  Ok I guess I could go on and on for pages...but I'm sure I'm not saying anything alot of you out there haven't already felt and experienced yourself.  Maybe tomorrow will be a better day...and maybe a day soon to come of determination to fight..but tonight..I'm hangin it up.