Question for Gary Viscio!

Gary, I have BCBS of Illinois and they require 6 months of clinically-supervised, non-surgical program of weight reduction, occuring with the 24 months prior to the proposed surgery. They suggest Optifast, Medifast, Weigh****chers, Jenny Craig, etc. It doesn't say anything about the visits being consecutive, as long as they consisted of nutritional therapy, behavior modification, counseling and instruction on exercise and increased physical activity, and ongoing support for lifestyle changes to make and maintain appropriate choices that will reduce health risk factors and improve overall health. In the last 24 months, I have visited the doctor many times. In 2005, I was pregnant with twins and lost 1 1/2 lbs during the pregnancy because I was on the Atkins diet. My ob/gyn didn't write anything about my diet, but the records show my weight loss and the fact that I had ketones in my urine(which is common when you are on Atkins Diet; it means your body is not getting nutrition enough to sustain itself, so it has to pull energy from fat reserves.) Also, during the 24 months, I went to my PCP at different times (not all consecutively)for Adipex approximately 7 times or so. I started my 6 month visits to my PCP last week, just in case they don't accept what I already have. I also started Nutrisystem a month ago. My surgeon is sending in my letter of medical necessity along with my records today. He feels that they might accept it since it shows my attempt at weight loss. I have four questions:      1. Does Adipex count as non-surgical weight loss attempts?      2. Does BCBS of Illinois have to accept my attempts during the last 24 months as sufficient evidence?      3. If they deny me, do I need to appeal or continue with 6 months of supervised diet attempts with my PCP?      4. If I appeal, what do I need to submit along with the appeal? Thank you very much! Karen

Yes, No, Yes, Everything.

If the adipex was under doctors supervision it would count, but in any case they're going to look normally at consecutive months.  If they deny you, then you should appeal, and while you do that, undergo the 6 month diet program just in case you lose your appeals. 

There is a post above about the six month diet requirements.

If you appeal, send them everything you have.