6 Month Bariatric Program required

My doctor enrolled me in this program. I have Health net/Facey. The WLS class is 10 weeks and she said in the 6 month period I just have to see her 3 times. Then after the 6 months I get the surgeon referrel. and then they said all the paperwork to Health Net for approval. My doc say no one she has ever referred was denied.

I guess I am just worried about going through all this only to get denied. Has anyone gone thru a similar program and been denied.

My insurance says I have to be 35-39 BMI with co-morbidities which I don't have the big 3 but I do have GERD & DDD.

Or a BMI of 40 and higher and no co-morbidities and my BMI is 42.3. the only thing she told me is don't go out now and lose 50 lbs, As if?

So I am stressing. PLUS...The classes are full until May/June.

Try not to stress out. I know it is easier said than done, but I'm sending good thoughts your way. :)

Thank you so much Rosie...I need them!

 Are you in CA? If so read this thread. http://www.obesityhelp.com/forums/amos/3866637/Denied-a-refe rral-for-not-having-6-mo-phys-doc-diet/#31043820 Ask your doc to refer you for consult now. Tell her you know that it will be denied but that you will appeal directly to HN. Bring her the peer review from the DMHC and the 2 IMR decisions. If you're trying to get approval with Health Net it's not that hard once you actually get in to see the surgeon.



Edited to add: while you are waiting for the consult make sure that you research all  your surgical options. The DS, VSG, RNY and lapband. 

Thanks Calimom

My doctor did not say anything about a 6 month diet at all. She said I do the 10 week classes and just visit her 3 times in that 6 month period. I brought her all my WW books from the last 10 years.  She kind of made it sound like she would be "creative" with her letter...not that she would lie but I guess be in depth. And she made a point to tell me not to go out and lose 50lbs.

She explained that all they want to do is make sure I am serious and not going to back out. She took note of every diet I had been on and what I did. She said "you are a prime candidate and don't worry, wls will happen"  The only thing holdng me back at this point is the classes are full until May...I was told to call in mar*****ase someone dropped out.

I keep hearing how easy Health Net is to get approval.

oh and yes I am in cali....maybe that's why she never mentioned a diet...just 6 months of learning.

 6 months of  "learning" isn't required. You should just bring the peer review into your PCP and ask her to refer you to a surgeon now. It will be denied by your medical group. You appeal to your insurance using the peer review and the IMR decisions and you'll have your approval for the consult in 30-60 days. My medical group took 5 days to deny my PCP's referral to a bariatric surgeon. I filed an appeal with HN and got an answer in 30 days. Once I got the letter from HN stating that they were overturning my medical group's denial I was able to make an appointment with the bariatric surgeon. Why wait until May to get in the class when you can get a head start now. Best of luck to  you in whatever you decide to do. 

PS if your PCP is this supportive I think she wouldn't have any problems referring you now without the classes. Alot of doctors and even surgeons in the state of CA do not know that we do not have to lose weight, attend classes, give up our first born to get referred for WLS. My PCP didn't think I would get the referral before I completed my six month diet with her but I did.

Do you know if this works with Kaiser since everything is in-house?  My hubby was immediately referred into the program because of BMI and severe sleep apnea, but we were told that after the orientation he would have to take 6 months of classes.  Since insurance and physicians are all part of Kaiser, any idea how to appeal or with whom?

Alecia

 You need to file a grievance with Kaiser directly about the 6 month supervised diet. Did your husband get a letter stating that he was accepted into their bariatric program? If so take that letter, along with the info on my page about not doing the 6 month diet, into Kaiser and file a grievance. They will deny the grievance because they'll say that it's required, blah, blah, blah.... But once you get that denial letter, file a grievance directly with the DMHC and you husband will not have to do the diet and will then get referred to a bariatric surgeon. PM me if you have questions.

I'm not sure if we have a letter, but he is definitely in the program.  He has an appointment for the next available Options class in July.  They are calling it a "class" for health education and to prepare you for the surgery, etc.  They don't seem to be pushing the weight loss aspect although it is "encouraged".  They do say that the 24 week "class" is required.

I will file a grievance to not attend the class.  Since the info on your page seems to focus on a 6 month diet, I wonder if it is applicable in this case.  I need to show that a health education program prior to surgery is not necessary.  What are your thoughts?

Thanks for all your advice!!!