denied/no 6-month diet in past two years

"Does anyone one have Healthnet Advantage Platinum in New Jersey? I have Healthnet insurance and they have been great until now. They have denied coverage for the surgery saying that do not meet medical necessity because I did not provide documentation of a 6-month supervised diet in the past two years. I agree that I have not participated in a supervised diet in the past two years, however I did supervised diets in 2001,2002 and 2003.  My surgeon had a peer to peer review with a medical director at Healthnet and they refused to reverse the denial. I was told by my surgeons office not to worry about the 6 months requirement because everything would be okay. I guess that I shouldn't have listened to them. I did LA weight loss in 2004 does that count for anything? I don't think that my surgeon included that information. Do you think that I will have any success on appeal.  Has anyone had deal with Healthnet in this manner. Also if anyone has a sample appeal letter I would greatly appreciate any help. Thanks,  

I don't think the LA W.L. program will helo your particular situation.... but if you've got documentation on it, it probably wouldn't HURT to at least show you've made steps.... USUALLY, insurance companies don't accept (as their "supervised weight loss attempts") programs like Jenny Craig, Weigh****chers, etc.... unless you're ALSO making monthly visits with your doctor and/or health care professional (like a dietician/nutritionist) for regular weigh-ins and counseling good luck.

Trust me they won't budge on the 6 month requirement. I got denied 2 times by a different company this year and now I will have to file an external appeal. Talk to your Doctor and get him to make sure they bill it for obesity related issues - I was told that unless it was billed corrrectly they could question whether it was a Supervised diet. Your visits could be no more than a weight in and a discussion of what your doing to lose weight. I've been working on this since last fall and my Doctor also did a peer to peer review only to be told they would not reverse the decision. I thought the 6 months would last forever but they did not I only wish they would have approved me and if I hadn't pushed the 2nd review prior to finishing my 6 months I might be approved now instead of pre-paring for an external review.

Hi there, Sorry I don't have an answer for you although I do have a copy of Health Net's policy on bariatric surgery and it does say it will count documentation from a weight loss center (meaning WW or LA Weight Loss) so I'd order up the documentation asap! I'm wondering, also...at what point were you denied? Had they already approved consultations and pre-op evaluations and testing, or had you not done that part yet?

Hi,  They have already paid for all of the pre-op evaluations. I had completed everything and was ready to go for surgery, even had the date set. Sharon

I am in the same boat.  I was denied over a year ago and this October I will be completeing my 6 month of dieting with Dr.  I only hope they do not decide to denie my for something else.  My advice is to definately get a copy of requirements from your insurance company of what they need to approve this surgery.  Best of Luck to all. 

Anything new about your approvayl? I have Healthnet, and am kind of worried.  I saw t he doc, discussed wieght loss, went on a diet btu did not see him too much about it; lasted 7 months, then I stated again last May...waiting for approval, but has been only a few days since it was submitted... Hope you are having good luck!!! Cindy

Hi Cindy, I have nothing new to report. I started drafting my appeal letter but my mother passed away on 9/22/06 and I have been busy with funeral arrangements and family. When I am back home next week I will finish the letter and submit it. Also, I am just going to start on a 6 months diet just in case that is ultimately necessary. Then I will be abel to have surgery in April. I wish you the best. They got back to me really fast with theit decisions so hopefully you will hear from them soon. --Sharob