Gary: Fighting PacifiCare's 6-month plan in California

Question for Gary. I noticed you stated that a 6-month diet plan is not generally required in the State of California. I'm fighting with PacifiCare Signature Value Care plan, because they are requiring me to do a program called "Healthy Roads." I received a denial letter stating that I "do not meet the medical necessity criteria or guidelines at this time." They are saying I MUST complete their 6 month program called "Healthy Roads." HOWEVER, I have my plan benefits in front of me and under Morbid Obesity, it says, and I quote: "Morbid Obesity (Surgical Treatment) - PacifiCare covers Roux-en-Y gastric bypass or vertical banded gastroplasty [now vertical sleeve gastrectomy] surgical procedures when Medically Necessary and Preauthorized; PacifiCare utilized the National Institutes of Health (NIH) Consensus Report criteria as a factor for determining the Medical Necessity of requests for surgical treatment for morbid obesity." NOWHERE in that statement is there a caveat that one must complete this program. I've also been told by DMHC (Department of Managed Health Care) that PacifiCare is being investigated for this practice.  I've filed a grievance with Pacificare as of 7 July 2007. I'm in a particular bind because I can't get listed with the UNOS transplant services until my HMO approves my surgery; and I NEED a kidney transplant to get off of dialysis. HELP! :(

While you're fighting them stay on the diet. Get the appeal going and file with DMHC for an external review. Many of these companies are throwing in these strange requirements to wear you out and frustrate you. Really fight them.  You're in the right here and your written policy controls.  Keep on top of them and keep on DMHC in regard to your complaint. g

Meg, i have pacificare HMO, and first time i was denied as well because I needed to have 6 months of Healthy Roads as well. So i jumped on it, wasnt happy about it at all, talking to coach every week etc. but you know what, just play along with them. They want you to quit and not go through with it. I did, with the help of my family. I finished my 6 months in june, and next tuesday i have an office day with my surgeon, will get a date:) very exciting....

I, too, have Pacificare Insurance and am currently in the six-month program through HealthyRoads.  The counselor calls once a week and they sent books, a pedometer, exercise bands, samples of their products they would like you to buy (vitamins, snack bars), and a recipe book.  The counselor wants you to set "goals" each week on how you will improve.  It's things like eat more grains, increase your water intake, or get in more exercise.  Asking questions:  How many times did you eat red meat? - Have you seen the doctor since we last spoke? - Have you weighed?  There are times I feel I know more than the counselor!   I cannot increase my exercise because of my knee sprain until I get to lose weight and I cannot lose weight until I get the surgery......  Waiting six months for surgery will mean I am six months older, my knee will have not been much improved by another six months, and I am not losing any more weight because the counselor at HealthyRoad is making me eat Carbs........  I've lost about 14 pounds in two months because I've been eating a "bariatric" diet.  I haven't lost much since HealthyRoads has asked me to eat 6 servings of fruits and vegetables and 3 servings of grains.......  I am doing this program because I was told I have to do it as part of their program but the length of time seems long.  In two months, I've gotten everything out of it that I am going to get out of it.  I understand water intake, balanced diet of foods, and exercise is important. I'm ready for more!

Ugh. That is so crappy!!!!!! That's why I'm fighting this; I have a very specialized diet I'm on because of the renal failure and changing it will be detrimental to my health. One of my friends, Monica P. fought and won, so that's what's spurring me on for my fight. She hired an obesity lawyer here in CA and I found out that DMHC is investigating PacifiCare's healthy roads requirement. Yay!

I guess I should have mentioned that I'm on dialysis for kidney failure and I can't get listed with the UNOS transplant services to get a kidney transplant until PacifiCare approves my surgery. So now I've got my doctors working on this. The kidney transplant services at Standford WILL NOT list me for a transplant because I need to lose the weight, and so I can't do anything really until the bariatric surgery is approved. Every month that it is delayed it costs money, time, and health. This surgery is a REQUIREMENT to save my life. THAT is why I'm fighting it. :)