X-Post: What exactly does my PCP have to document?

Okay, going to try and make my long story short.  I'm appealing to my insurance so that maybe I can have my surgery before the end of the year.  I started the appeal process before open enrollment.  We are in open enrollment now and I recently discovered that as of January 1st, WLS will be covered under some of our health insurance options.  So, if the appeal doesn't go thru, I'll just wait until the new year (not a big deal...I've waited this long).

Anyway, I already started the 6 month visits with the PCP to document.  I do like my PCP and he is all for the surgery, but after seeing his letter (if that's what you want to call it) of medical clearance/necessity, I'm a little concerned about what his documentation may (or may not) include.  I am doing Weigh****chers (and have most of the last 7 years of documentation of weights for it).

So, the question is, "What exactly does the PCP have to document to satisfy the insurance companies?"

The other question I have is about the "spacing" of the 6 months worth of visits.  I did my first visit on October 1st.  Do I go back on October 31 (30 days) or November 3 (because Nov 1st is a Saturday)?  Are they that anal about the visits?  Or if I don't make it to the doctor until November 6th, would that be a problem?

I have 2 insurance company choices, UHC & Cigna.  UHC seems like their requirements are going to be more stringent (it's still being ironed out, but something about 6 months worth of PCP visits AND a behavioral weight management program).  Cigna indicated that with 7 years of documentation from WW, they might not be as anal about 6 months worth of PCP visits.  I'm leaning toward UHC because they were able to verify my hospital was in their bariatric surgery plan.

Thanks for the advice!
Elli

I would call and talk with the insurance company about their requirements and get them in writing.  Then I would attend some free information sessions at WLS centers and talk to them.  The insurance company can give you the written policy, but maybe not enough details about what exactly has to be docomented.  The WLS center should know exactly what is required.  this is what I did. 

By the way, for my insurance (BCBS MN) they require 6 month med sup diet attempt.  According to my WLS insurance guru, that means, "discuss weight management, healthy lifestyle, nutrition and exercise" in 6 montly appointments.  You don't have to be on a diet.  The 6 appts should be in consequtive months but don't have to be 30 days apart.  When I called BCBS they didn't give me nearly that much detail, just said a 6 month medically supervised diet attempt - they even said I didn't have to go in 6 times - I don't believe that, so I will be doing 6 consequtive visits like my WLS clinic told me to do.

good luck - make sure you do exactly what the WLS people tell you.  They deal with this all the time and know best what to expect from your insurance company.

Unfortunately, my employer is just adding the WLS for the new year (after years of not covering it).  And they seem to be writing the policy anew every day!  My employer is putting things into the policy that the insurance companies don't generally require.  NOTHING is in writing yet.  And each time you call and speak to a different customer service rep, you get a different answer. 

Oh well...  Thanks for your input.
-Elli

I just wanted to say that CIGNA does not cover the VSG. They will cover the DS for BMI over 50. As far as UHC, I don't know if they cover the VSG but I do know they are great about approving the DS.

Click in my signature for the CIGNA coverage position. CIGNA does want a 6mo medically supervised weight program. If it were my choice, I would choose UHC and not be fighty CIGNA right now........ Thats just my opinion.

I am waiting approval so I'm no expert on what they want. I got two letters from my PCP. One recommending WLS and why and one for the 6mo diet. We documented 9 months of visits with 2 months missing in the middle and for each visit we documented my weight, vital signs, and diet and excercise plans and progress. We also send the doctors progress notes from eash visit. I hope it works.

If your not happy with his letter, then write one yourself and see if he will sign it.

Good Luck!


Edited to add: Oh by the way, you have one of the best DS surgeons in your back yard!!! Dr Dennis Smith

 Welcome to the world of the insurance run around. If I were you I'd keep going to my PCP once a month, every month for 6 months while you wait for your new insurance to kick in. No matter what they will probably require some kind of supervised diet. You do not need to go every 30 days,  you just need to make sure the visit is in the next month. So sometime in Nov, then Dec, and so on until your 6 months is done. Make sure you discuss with your PCP what you are "doing" to lose weight, make sure they document everything, your diet, exercise, etc. When your PCP does submit for WLS have them submit your documentation from WW at that time too.
I do not think that any insurance approves VSG yet. Most still consider it investigational or experimental since it hasn't been done as a stand alone procedure for too long. Maybe as more studies are published and more long term results are recorded that will change. Like someone else said the VSG is one part of the DS and the DS is approved by medicaid/ medical/ and most insurance plans. Have you looked into getting the DS?
PS keep a log of everyone that you speak to and conversations you have with them. That way you can document what they told you was required to get approved for WLS. That will only help you if you have to appeal. Best of luck

I know that the insurance doesn't cover VSG, but I haven't changed it in my profile yet...I have to have a show down with my nephrologist this Friday about that.  I was planning on RNY originally, but my nephrologist wasn't keen on that idea due to the potential for chronic kidney issues (I already have autoimmune disease and have very mild kidney involvement).  So, I planned on VSG with the high probability that I would be paying out of pocket.  Now that my insurance WILL cover WLS, but not VSG, the nephrologist and I will have to discuss it again.  I'm pretty sure the DS was out of the question even more so because of potential kidney issues for me.  Besides, since February, I've lost nearly 60 pounds...BMI has gone from 59.5 to 51.6.  I can't have surgery until at least March (if I'm lucky).  I would suspect by then, I'll have a BMI < 50.

Thanks for the input!
Elli

 Insurance can be made to cover the DS with a BMI < 50. I know with my insurance, Health Net, their medical policy states that they will cover the DS with a BMI >50 but I know of a couple of people with HN who have BMIs less than 50 who had the DS with HN. They were initially denied but upon appealing HN's decided to pay. There are no published studies or peer reviews that state that the DS should only be reserved for patients with BMI> 50. Medicare covers the DS with a BMI >35 and at least one comorbidity. The NIH states that a patient is a candidate for WLS if they have a BMI > 35 with comorbid coditions or BMI > 40 without. No where do either Medicare or the NIH state that the DS should only be reserved for the SMO. As to the kidney issues I can't speak to that since I don't know anything about that  but if your nephrologist thinks that getting the DS will not effect your kidneys any worse than the RNY I wouldn't worry if your BMI does get below 50. I too have kidney issues, one kidney doesn't function fully but the bariatric surgeon I went to see didn't t hink it would be a problem. Best of luck to you in whatever you decide is best for you and congrats on the great weight loss.