Help me understand, what is our next step?
My bariatric surgeon's office has filed for insurance approval for my husband and I both to have RNY. After the insurance co. (PHCS PPO) reviewed it they denied me and have requested additional info for my husband. I have not received my letter stating why I was denied but I did receive my husband's letter today.
It seems that the requirements are different than what we have in our medical insurance handbook. Please take a look at the following and give me any suggestions or hints on how we should proceed. I know that our Drs. office will appeal but I just don't understand the insurance wording.
Thank you so much for your time,
Jen
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The PHCS policy states the following:
Morbid Obesity Treatment: Surgical procedures for Morbid Obesity include, but are not limited to: stomach surgery (gastoplasty), stomach stapling (gastric stapling), stomach bypass (gastric bypass), and surgery for the removal of fat from the belly (panniculectomy and abdominoplasty). Surgical treatment for morbid obesity must be provided by an in-network designated weight loss surgery provider and is limited to: (A) BMI -Your Body Mass Index (BMI) must have been greater than 40 for at least two year. (We both meet this requirement at 47 and 57) (B) Co-Morbidity – BMI of 35 meets criteria if clinically significant co-morbidity and failed to respond to non-surgical methods of active management attempt for co-morbidities such as hypertension, coronary artery disease, esophageal reflux, etc. (C) Risk Factors – There must be an acceptable age and risk for surgery. (D) Psychological Evaluation – A preoperative psychological evaluation is required. (Completed) (E) Weight Loss Programs – Must have had 2 unsuccessful attempts occurring within the last 2 years with a structured program of three to six months in duration. (We both have a med sup diet for 3 months from our surgeon and the other attempts were not documented by a doc...) In order to consider benefits, the following pre-procedure requirements must be documented: (A) Non-surgical methods of weight reduction must have been attempted within the past 12 months and include: medically supervised dietary regimen for at least 6 months and lifestyle management and support. (B) Correctable endocrine disorders and/or other medical conditions have been ruled out. (C) Psychiatric and chemical dependency contraindications to the surgery have been ruled out. (D) You understand the surgical procedure chosen, the side affects, the expectations/results; and. (E) You commit to participation in close nutritional monitoring during rapid weight loss, long-term life-sttyle changes, diet prescription, and medical surveillance after surgical therapy. Benefits will not be payable if the following has been determined: (A) The Body Mass Index (BMI) less than 40. (B) The BMI of 35 to 39.9 does not have documentation of co-morbidities listed above. (C) You are considered a high surgical risk. (D) There is an untreated endocrine disorder. (E) There is a presence of psycho/emotional problems which be intensified by the surgery. (F) You and/or Your Dependent are less than 18 years of age. (G) Services are being provided by an out-of-network provider or a provider that is not a designated weight loss surgery provider. (H) Prior approval has not been obtained. The request for additional info letter from insurance asks for the following:
1. Complete preoperative psychological evaluation which addresses both psychiatric and chemical dependency contraindications to the surgery have been ruled out. (Completed) 2. Documentation of 2 unsuccessful weight loss programs occuring in the past 12 months with a structured program of 3 to 6 months's duration. 3. Documentation of non-surgical methods of weight reduction within the past 12 months that inculde a medically supervised dietary regimen for at least 6 months and lifestyle mangement and support. 4. Medical record documentation that correctable endocrine disorders and/or other medical conditions have been ruled out. 5. Documentation that the patient agrees to commit to participation in close nutritional monitoring, long term life style changes, diet prescription, and medical surveillance after surgial therapy.
The PHCS policy states the following:
Morbid Obesity Treatment: Surgical procedures for Morbid Obesity include, but are not limited to: stomach surgery (gastoplasty), stomach stapling (gastric stapling), stomach bypass (gastric bypass), and surgery for the removal of fat from the belly (panniculectomy and abdominoplasty). Surgical treatment for morbid obesity must be provided by an in-network designated weight loss surgery provider and is limited to: (A) BMI -Your Body Mass Index (BMI) must have been greater than 40 for at least two year. (We both meet this requirement at 47 and 57) (B) Co-Morbidity – BMI of 35 meets criteria if clinically significant co-morbidity and failed to respond to non-surgical methods of active management attempt for co-morbidities such as hypertension, coronary artery disease, esophageal reflux, etc. (C) Risk Factors – There must be an acceptable age and risk for surgery. (D) Psychological Evaluation – A preoperative psychological evaluation is required. (Completed) (E) Weight Loss Programs – Must have had 2 unsuccessful attempts occurring within the last 2 years with a structured program of three to six months in duration. (We both have a med sup diet for 3 months from our surgeon and the other attempts were not documented by a doc...) In order to consider benefits, the following pre-procedure requirements must be documented: (A) Non-surgical methods of weight reduction must have been attempted within the past 12 months and include: medically supervised dietary regimen for at least 6 months and lifestyle management and support. (B) Correctable endocrine disorders and/or other medical conditions have been ruled out. (C) Psychiatric and chemical dependency contraindications to the surgery have been ruled out. (D) You understand the surgical procedure chosen, the side affects, the expectations/results; and. (E) You commit to participation in close nutritional monitoring during rapid weight loss, long-term life-sttyle changes, diet prescription, and medical surveillance after surgical therapy. Benefits will not be payable if the following has been determined: (A) The Body Mass Index (BMI) less than 40. (B) The BMI of 35 to 39.9 does not have documentation of co-morbidities listed above. (C) You are considered a high surgical risk. (D) There is an untreated endocrine disorder. (E) There is a presence of psycho/emotional problems which be intensified by the surgery. (F) You and/or Your Dependent are less than 18 years of age. (G) Services are being provided by an out-of-network provider or a provider that is not a designated weight loss surgery provider. (H) Prior approval has not been obtained. The request for additional info letter from insurance asks for the following:
1. Complete preoperative psychological evaluation which addresses both psychiatric and chemical dependency contraindications to the surgery have been ruled out. (Completed) 2. Documentation of 2 unsuccessful weight loss programs occuring in the past 12 months with a structured program of 3 to 6 months's duration. 3. Documentation of non-surgical methods of weight reduction within the past 12 months that inculde a medically supervised dietary regimen for at least 6 months and lifestyle mangement and support. 4. Medical record documentation that correctable endocrine disorders and/or other medical conditions have been ruled out. 5. Documentation that the patient agrees to commit to participation in close nutritional monitoring, long term life style changes, diet prescription, and medical surveillance after surgial therapy.
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