Help understanding policy

I live in Missouri, but have BCBS-PPO of MI. I did FINALLY get them to send me a list of my requirements. I need someone to break down to me exactly what they need it my charts or additional info.

The patient has been clinically evaluated by an MD or DO. The physician has documented failure of non-surgical management including a structured, professionally supervised (physician or non-physician) weight loss program for a minimum of twelve consecutive months within the last four years prior to the recommendation for Bariatric Surgery. Documentation should include periodic weights, dietary therapy, and physical exercise, as well as behavioral therapy, counceling and pharmacotherapy, as indicated.

Documentation that the PCP and patient have a good understanding of the risks involved and reasonable expectations that the patient will be compliant with all post-surgical requirements. I started seeing my current PCP in November 05 for weight loss. I did miss December and January, but did go to the dietician he sent me to in January. I have gone monthly since then. When would my 12 month diet be complete? My PCP said I didn't need to go every month, but I am worried missing Dec. and Jan. will mess me up. Also what should be getting wrote in my charts? Anything else I should be doing? Thanks! S Goodman

It is my understanding that they are pretty strict on the consecutive visits.  If you miss a month, they could use that to deny you.  I have BCBS of Alabama and this is what I did to get approved.  I had to do 6 consecutive months supervised diet.   Also I don't think you can just go to your doctor and get weighed and have that documented.  You must get your physician to write a progress note at each visit, indicating what diet and exercise program you are on and what your response to the diet has been.  I didn't lose a lot of weight (30#) but they do want to see some weight loss to indicate that you are capable of making the changes needed for surgery.   Before you submit and get denied, find out what the appeal process is for your insurance company...some of them limit the number of appeals you have...if that is the case, you may want to make sure you meet all the requirements before you submit.  If you have several or unlimited appeals, you could try to submit and just see of they will approve you even though you missed a couple of months.  I certainly would not miss any more and get your PCP to document properly at each visit. Hope that helps,

How do I go about finding my insurance's appeal process? Thanks!! Shonna

Consecutive. It's a word that needs a bit more clarification, I think.   My insurance company defines "consecutive" as being 12 months in a row of dieting within a 4-year time frame.  Meaning I can't be on a diet for 3 months in 2003, then on another diet for 9 months in 2005.  It has to be 12 months of dieting during a 12 month time period.  They DO NOT require that I be at my doctors office every month for 12 months, just that the doctor has documented during a 12 month time period that I've been dieting, blah, blah, blah and all that other stuff.  BCBS have told me specifically that 3 visits within that 12 month period of time is sufficient. I think surgeons' offices and SOME people's experiences have clouded the issue and the real definition of the term. When speaking to your insurance company ask that question specifically to make sure you fully understand what they mean by the word "consecutive". HTH Pam