Can they REALLY require THREE YEARS supervised?

Okay, I have BCBS of AZ (PPO) They have a pre-authorization company they use: American Health Group (AHG) AHG has a boatload of requirements to be approved for WLS and as far as I can tell I meet all the requirements, but right now they're "sticking" at two of the requirements.  One of them is "five consecutive years with BMI > 40" ... well I have medical records going back to 1996 saying I've always had a BMI greater than 40, and in the last six years it's been between 50 and 60. BUT I don't have records for 2003 (I'm still sending for some records that MIGHT have my weight from that year, but don't have high hopes). Now, I can live with this one, as I get the impression that if I get weighed on Jan. 1st that will make five consecutive years.  The second one is more tricky. They require that I have been trying to lose weight for the last three years and have failed in my efforts and have doctor's records to back that up. They don't say I have to have been in a specific program, but just that I've been dieting under a doctor's supervision and haven't had success. Well I have. I"ve spoken about my efforts to my doctors when I've visited them. More exercise than diet, as I've never EVER lost weight on a diet, but HAVE lost weight even when not dieting, when I'm exercising. Apparantly the docs haven't WRITTEN it down at all those appointments, so the insurance company is implying that I will have to have a THREE YEAR supervised diet to even qualify for this surgery. Never mind my worsening co-morbidities that are going to make it impossible for me to work in another year. Never mind the fact that my BMI is in very dangerous territory. Never mind that my family history is full of life-threatening co-morbidities that could KILL me.  Can they really require THREE YEARS???  I live in hope that when the pre-auth group turns me down, that BCBS will give me something sensible like a 6-month supervised diet... which I've been doing since August. But I fear that their current requirement is only a stonewalling tactic. They can change their requirements a million times between now and three years, and by the time three years rolls around there could be an exclusion!  Anyway, I had to vent.

Wow!  3 years seems a bit excessive.  I have no idea if they can really stick to that requirement or not.  However, I know that BCBS typically requires 12 months of diet history.  I just finished my 12 months last week. When you call the phone number on the back of your insurance card do you get BCBS or AHG?  If you can get the written requirements from BCBS that's probably your best bet.  As them to send you a letter that details the specific requirements you need to meet for the surgery.  I did that and it's been very helpful when talking to my doctor or any other medical professional I encounter.  I know what the requirement is and I can make sure that the notes from that particular doctor visit reflect what is required. Good luck Pam

BCBS refers me straight to AHG... AHG says that while BCBS has requirements they aren't nearly as strict as AHG... but AHG has to pre-certify.

So I have to wait until they are done and reject me, and then see if there is anything I can do... I've started monthly visits to my doctor so that I am prepared if they ask for a 6-month or 1 year supervised diet.

I wish there was a certain point beyond which the insurance company says "Gee, you REALLY need this surgery, so come on down and get it"... my psychologist feels that I'm a great candidate, my doctor feels that I'm a great candidate, and so does my surgeon. Now we leave it up to the most un-medically inclined folks to make the final decision!

Stoopid!

Just wanted to let you know all BCBS requirements are not the same. I have BCBSIL and they require 6 months. Not sure about the 3 year requirement though.

Sounds to me you should try to get a lawyer. This sounds like one of those stall tactics!  Evil! I hope things turn around for you soon.

if that is the insurane companies requirement then there is nothing a lawyer can do, it is what it is.  ask for the criteria in writing.

Just a thought...are you sure it didn't say "dieting for x months within the last 3 yrs?" Get it in writing, and I would contact the AZ Insurance Commission, and ask a lawyers there. This seems to be WAY outside of the industry standard of 6-12 months. They need to be able to justify why they want 3 yrs, as that sounds completely arbitrary. Like Meg said, she got a lawyer and was able to overturn her insurance's 6 month requirement (she did have some extenuating cir****tances however). Good luck, Kahlua

Kahlua,  Thanks for your words of encouragement. I'm still in the very beginning of the fight. I am planning now several ways of fighting them (so they can't make me do the 3 years). I have been working with a doctor for three years, but alas, every visit to the doctor was based on some other medical need and the discussion about diet and exercise was always an "aside" with the doc. I'm going to see if my doc will write up a letter explaining the discussions we've had and the way I've been working on diet and exercise for the last three years and how it didn't show in the records. Hopefully that is enough. (one can hope). I'll also get my Bally's and YMCA records and add them to the mix)... I'm not done fighting. I'm just discouraged because until I have RNY or something else is done about my GERD, I'm in constant pain every time I talk due to the erosion of my larynx. Either the insurance company is going to pay for RNY or some other equally expensive operation, and if I lose my voice permanently, as seems likely, I lose my livelihood. (I'm a teacher). And as overweight as I am, I am doubtful that any other GERD operation will be fully successful until/unless the weight comes off.  I know insurance companies bank on you not staying with them for very long and becoming someone else's problem, but teachers are often the exception. Statistically I'm a BAD risk for them NOT to pay for surgery.  Ah well.. the fight goes on! At least in the meantime I'm not sitting around stuffing my face in sorrow. (as I might have done in the past)... I'm eating well and losing. Just not sure how much I can lose and keep off on my own!

Lithia- I'm so glad you are up for the fight. Something like this is outrageous!! 3 yrs??? But if it doesn't have to be doc supervised then I'm sure they should accept your gym memberships. Also if you have any "sample menus" from your dieting, a food log, etc, that should suffice. You should also state that there was NO way for you to know in advance about suck strict requirements and documentation, or you would have insisted you doc write everything down. Who would think of that in advance? Clearly they are playing games, but you are right. You will be with this insurance for yrs to come, and you should remind them of that, and the tremendous savings they'll see by addressing this problem now. Give 'em hell sista! We're here for support. Your efforts may even effect a change in their policy, which is so obviously a ploy. Good luck, Kahlua

Hi! my prayers are with you.  I have BCBS and they only required a 6-month.  You really need to get a copy of your policy.  They might have it on line. Angela