BC/BS AL. questions about pre-determination yadda yadda

Ok..I started my 6month diet feb. 11th..my PCP put me on Adipex..we'll see how it all goes I suppose..I just have a feeling I will not be approved for this surgery.  I'm 22, and have been overweight/obese since 15.  Pretty much according to bmi trackers I need to weigh 150 at most..however..220 and below will make me smile now...I would LOVE to be 180 though.  I currently am between 280-288 and am 5'5ft.   The letter I received..or rather the surgeon is this: Dear Dr. Baker: We are contacting you regarding the proposed treatment of the above patient. Our medical staff is unable to make a predetermination for the proposed treatment at this time.  In order to make a determination, our medical staff needs 3yrs. of medical records beginning in early 05 and continuing to present documenting the height and weight and med. record documentation of a medically supervised weight loss attempt in the past year for at least 6mnths consecutively.  This documentation must be in the PCP's records.  Letters are NOT accepted.  The patient must see the PCP monthly for a total of 180 Days.  The records must document diet, exercise and progress of the attempt.  Please note that the patient is serving a waiting period for pre-existing conditions.  Then gives fax number & address. First of All..I didn't start having a regular doctor til Jan 07 when I got pregnant...so I haven't really been to a Dr.  I have off and on when I really have to..but not a specific one til now...I finally found a DR I love..and he's a family doctor.  I have pictures dating back to 2003..but most are face pictures or what not..since I've always hated my weight.  Do I even have a chance at all..according to that letter..and 180 days monthly???  I don't get it..What I read in the BCBS AL. site was to vising the PCP monthly in the diet..a 6month diet..it also said something about at least 3 times visit or something..none of it makes sense.  What is this 180 day cr*p?  I am beginning to really just forget it.  I suffer from depression, chest pain, and circulation problems..heart disease & diabetes runs in both sides of my family.  They can see I have suffered from depression or whatever since 14..got off meds at 18..got back on them in october as my weight ran back up and what not.  I would love to do this without surgery..I don't even know if it is possible though.  I don't even overeat...if anything I undereat now...I quit eating until I got pregnant..but then I didn't even eat enough..and I still don't..sometimes I skip days, I know it's bad..but..why is my weight going up???  Would I even benefit from Lap-band surgery..as I don't even eat??  I'm trying to join a gym so I can tone up..get a personal trainer..it's just hard to get courage to workout in front of other girls my age...who weigh 130 and claim they are "fat" and are superficial.  What should I do?  I don 't even know how to deal with insurance..I'm clueless.

First of all, stop and take a deep breath. Insurance companies don't want to pay for this surgery, so they throw up all the roadblocks so people just give up. I am a nurse for a bariatric surgeon and send off pre-determinations for surgery.  I do have experience with BCBSAL. They require the 6 month medically supervised diet and it must be 180 days in length. If you make monthly visits for 6 months but they are not spaced out equally, it will nto equal 180 days. I had one patient get denied because it was 157 days, her first visit was on the 29th of a month and the last on the 2nd, anyway, it was not six FULL months. You need to see your PCP monthly, have your weight and vital signs taken and make sure your doc documents each month in his notes which diet you are doing, the exercise you are doing, etc.  As for medical records, get what you can. I have never provided 3 full years worth of records, only 3 years worth of weights. You can find one weight per year since 2005 from someone, any doc, OB, ER, anyone, even weigh****chers records if you have them. If you cannot, get a dentist or other health care professional you saw, counselor, etc to write a letter on your behalf that you were "severely obese" at the time of their treatment.  You can get this approved, you just have to jump the hoops. As for surgery, use this 6 months to really think about band versus RNY. If you have more than 100 pounds to loose, your chances of success with the band are slim. Yes, the band has worked for many people, I am not knocking the successes, but our experience (as well as nationwide) shows many patients are not satisfied with their weight loss. With a band you will loose around 60-80 pounds, with a RNY it will be 100-120, or more. Just something for you to think about because insurance is only going to pay for this once! If you are thinking the band is safer, it only is safer immediately post-op. The complication rate for a band rises as time goes by (parts wear out and fail), but for RNY it goes down over time. Good luck! Bonnie RNY 6/3/05 264/154

You need to appeal the decision and get your doctor to write a better letter.  They worry that your doc just writes a letter without really having seen you, thats why they want to see the progress notes.