Pacificare and medical group guidelines for 6 month diet

My surgeon sent in for approval on Friday for RNY and I got to thinking about the 6 month diet. I lost 30 pounds in the first 4monthsof the supervised diet. The endocronolgist told me I didn't NEED to lose any more weight to qualify me for surgery. I stop going to the classes and he sent me to the surgeon. Now I am worried that what if I should have still gone to the classes? My insurer no longer requires it after the did away with healthy roads so can I get denied for following whta my doctor told me to do?

Congratulations on looking to make a change in your life for the better!

My suggestion would be to do a few things:

     1.  Contact Pacificare's customer-service department , and talk with the representative about the details of your benefits.  That person will be able to share with you whether the six-month medically supervised weight-management plan is a hard-and-fast rule or if a certain amount of weight loss could act in its place.

     2.  Refer to your explanation of coverage (possibly referred to as summary plan description) to review what is in writing.  For popular procedures such as bariatric surgery, there typically will be a section or two detailing what the coverage levels are, if any, and what guidelines are in place to successfully certify the surgery.

     3.  If your benefits are offered through an employer (either your own or through a spouse or partner's), then speak with your human-resources department or benefits administrator to get clarification on the matter.

In the cases of dealing with medical groups, one is usually safe in following what the doctor indicates.  In other words, if the doctor states that something is medically necessary, then you can be reasonably secure in knowing that you will be covered.  Even in cases where the doctor is incorrect, the insurance company usually will allow you a way to remedy the situation without having to start over or to just give up. 

Ultimately, the worst-case scenario might be that your doctor was wrong, and you'll have to complete the additional two months in order to be certified to have the surgery.

I hope I was able to provide you with the answers you needed.

X-man

If you need assistance PM and I will be glad to do the research for you