I Really Just Need Your Opinion(s)!!! HELP!

Okay--I have BC/BS of PA and it covers RNY w/a 6 month diet & exercise program that is supervised by your PCP & you have to see a Registered Dietition/Nutritionist, but no specific requirements on seeing a Personal Trainer/Exercise Physiologist, etc.  My surg office sent my paperwork in & I was denied because they said that my first appt w/PCP (7/23/2007) and my next appt w/my PCP (9/2/2008) were the only two medical records I had.  My surg. office said my policy required "6 months cumulative supervision by PCPs" and that it didn't matter that I was going monthly.  My insurance company disagreed & said that I need 6 different months of appointments (they don't have to necessarily be consecutive--month after month--) they just have to all be w/in two years prior to surgery.

So...here's my question....I don't want to be denied again...I have 180 days from my denial to provide additional documentation for an appeal...so, I figured that in that time I would get more documentation & provide that so they CAN'T SAY I don't have 6 months....).....I have the following documentation:

7/23/2007 - PCP Appointment #1:  Met w/PCP & have medical records w/PCP supervising wt loss & exercise plan & discussing obesity, etc.
*  Then for three months I saw a Registered Dietition & joined the Y & had a personal trainer develop a work out for me, which I followed.  I have documentation of each time I visited the gym & worked out.

8/15/2007 - Exercise Month 1:  Meeting with personal trainer to develop exercise program; MicroFit Test performed w/written documentation of results.

10/9/2007 - Exercise Month 2:  Meeting with personal trainer re: exercise program I have been working for past months...Second MicroFit Test performed w/written documentation of results.

9/2/2008 - PCP Appointment #2 (okay--this was 14 months from my first appointment....that is my question....is that too long...my insurance just says 6 months cumulative supervised by PCP w/in 2 years prior to surgery....HELP!):  Discussion of diet (that I was on in August 07 through November 07)& exercise plan & discussed resuming that 2007 diet that Registered Dietition develop'd for me b/c I was not losing weight, but, in fact, gaining.

9/15/2008 - Exercise Month 3:  Meeting w/Personal Trainer & Third Microfit.

October 28, 2008 :  DENIAL by B/C B/S of PA, stating that I had not met the 6 month supervised diet/exercise & PCP requirement.  They basically admitted that I had e'thing else (my BMI is 43, so I don't need comorbidities, even though I have three.....)....
 
10/29/2008 -  PCP Appointment #3:  Discussion of diet from nutritionist & exercise plan--all well documented in med recs.

11/10/2008 - Exercise Month 4:  Personal Trainer & Fourth Microfit test.

11/13/2008 - 4th Meeting with Registered Dietition.

11/18/2008 - PCP Appointment #4:  Discussion of diet & exercise--well documented.  Also, discussion of meeting with new Registered Dietition & personal trainer.

12/11/2008 - 5th Meeting w/Reg Dietition.

12/15/2008 - Meeting with Personal Trainer & Fifth Microfit Test done.

12/17/2008 - PCP Appointment #5:  Discussion of diet & exercise--well documented in medical records.

I am going to do my 6th appointments w/my personal trainer for the 6th MicroFit Evaluation, 6th Meeting with Registered Dietition & 6th Appointment with my PCP in January....

So, do you think I am done???  Or, since that very first appointment was in July of 2007, which was 14 months before the 2nd appointment, should I do another meeting with Personal Trainer/Registered Dietition & PCP in February so that I am SURE I have 6 months?????

I know this is confusing & a lot of info, but I have until April to submit additional documentation and request an appeal---I really want to be approved this time...it is mentally draining getting denied, as so many of you know, & I want my documentation to be air-tight this time since they are only contesting the 6 month requirement.

So...would you all do one more appointment so I have 6 consecutive months?  Or, would you submit it after the January appointment & hope they agree that the July 2007 appointment satisfied what they want?

My thought as I am typing this is to do one more of each in February so that I have six months in a row....what do you think??  What would you do??? 

THANKS for replying....it helps so much to hear what e'one else is going through & thinks...xo.

"my insurance just says 6 months cumulative supervised by PCP w/in 2 years prior to surgery.." I would think as long as the appointments are all between July 07 and July 09, you are good.

Thanks for the input...I just don't want to get another denial...I am 50/50 on sending it to appeal in January or waiting until the first of February....the waiting game is nuts...but I don't have to tell you that!!!  Best wishes on your VSG...I really hope you get it!!!!  Micheala.

 I know that you are in the right, but why not just get in another PCP appointment, that way you don't have to worry whether or not they will accept the 7/07 appointment? What's another month in the grand scheme of things? Take it from someone who's been trying to have WLS for almost 6 years, you're better off doing the additonal doctor's appointment then having your surgeon's office submit.

I live in the state of CA and we don't have to do the 6 month supervised diet. My PCP referred me to the surgeon without it. It was denied by my medical group, I appealed to my insurance and was given the referral to the surgeon. Even though I knew that I didn't have to see my PCP I still did it while I waited for all referrals to be authorized. It took almost 6 months for all my consults and referrals to go through. Long story short. Even if you don't have to do something, doesn't mean you shouldn't, especially if it will make your approval that much easier for you this time around. Just my .02, best of luck to you.

You are right & I completely agree...after sitting on it for a while & thinking it through I realized that I can do an appt in January & then one the first of February & have 6 consecutive appts plus the one back in July 07---the more the merrier, right!  Since they have agreed I have everything except the 6 month supervised diet my appeal is only re: that issue...at least that's my opinion....with insurance companies anything can change!

I live in Tennessee now, but am originally from Nevada & went to law school in California (Sacramento)....thanks for your .02....and good luck!!!