On a 3 month (4 visits) Nutrition, Exercise & Therapy Program for BCBS Federal

My doctor's office called me last week and said that BCBS Federal called her and said, I did not have the required Nut 3 month visit reports.  She told me that I had make 2 more appointments with the Nut so I did.  I saw her on the 22 November and my next appointment with her is on 11 Dec.  I also received a letter from BCBS Federal yesterday saying that my predetermination was denied, because of not providing 3 month Nut appointment reports.  In addition, it was also noted that I was not in compliance with my 2 previous weight loss surgeries as far as dieting and exercising.  BCBS Federal on approved the LB back in 2008.  I did self pay on the Sleeve in 2009.    I called the doctor's office and she said when BCBS Federal called her they said they would be sending out a letter saying it was denied but she said they would accept the next 2 reports from the Nut when I complete them on 11 Dec 13.  She said don't throw in the towel yet! 

Has anyone else had a similar case like mine?   Thanks.

 

 

 

Update: I decided to go with Dr. Lana Nelson in Norman, OK.  If I could have started all over again, I would have gone with the RNY, instead of the LB back in 2008 and then revised to the Sleeve 2009.  Dr. Lana wants to repair my hiatal hernia once and for all and at the same time revise the sleeve to the RNY.  I am doing so well right now on the 3 month program that BCBS Federal requires.   These are my appointment dates, I hope they are according to their requirements:

1st Visit on 08-25-14

2nd Visit on 09-29-14

3rd Visit on 10-27-14

4th Visit on 11-24-14

 

  

I can only reply regarding the dietician visits - I didn't have a revision, and I don't have BCBS Federal (I have Aetna).  But, I was told that I had to do a 3-month multi-disciplinary supervised diet/exercise regimen.  It was crucial that it was at least 90-days.  If it was 89-days, the surgery request was denied. 

From what I understand, if you need 3-months of dietician visits, that means you need 4 dietician visits.  For example, the first visit on 8/12, the second visit no earlier than 9/12, the third visit no earlier than 30 days past the previous visit (approx. 10/12), and the last visit no earlier than 30 days past the previous visit (approx. 11/12).  This would give you 3 months of documented dietician visits.  I am pretty sure all insurances look at these visits this way.

Good luck!

I appreciate you chiming in.  My first consultation appt. with the dietician was Oct 16 she said we could meet again the next appt on Oct 30.  Next visit was Nov 22.  My next appointment is Dec 11.  I suppose I will have to do another visit to make it 4.  But the days between the visits are too early.   I was trying to get my visits done as soon as possible so I could get the surgery done before January.  

Looks like i scheduled all these appts wrong.  I bet that I will have to start all over again.    I am going to call BCBS tomorrow to confirm that.  

So did you have to do your appoints all over again since it was not 90 days?  

No, I had heard the horror stories and submitted mine after 105 days, just to be sure. But the people I know didn't gave to do them all over again, they just needed to continue until they reached the requisite time. Calling is a good idea. Good luck!

Hi noftessa0401, I'm back.  Sorry I didn't reply sooner.  I decided to go with another surgeon that is closer to where we live.  

I am having more problems with acid reflux and my hiatal hernia has grown bigger.  My surgeon said repairing the hiatal hernia by getting the RNY done is really the only option for me.  I have my appointment with her this Friday, August 15, 2014.   I will keep you posted.

Thanks 

My first appt was July 12 then August 12th, Sept 13th and October 11th!  I thought that Sept 13th was going to be the last but it was 3 months from the first visit.

Your two appt. you had in Oct wasn't a good idea!  Remember 30 days from the last appt.  Good luck!

Hi pharmagirl_45,  Thanks for your input.  I have been gone for awhile. I have decided to go with another surgeon, my first appointment will be this Friday August 15, 2014.  I will see what they say, and I will keep in mind what you suggested the 30 days from the last appointment.   

 

~~In addition, it was also noted that I was not in compliance with my  2 previous weight loss surgeries as far as dieting and exercising.~~

This is the one that is going to be tricky for you.  The Nut appts are easy  enough to take care of.

Ins co's are really cracking down on wls folks who have surgery after surgery.  Most ins co's are going to a "one wls per lifetime" rule and they are being hard nosed about it as well.  Even if someone was self pay for their surgery and they want a revision... the ins co's are looking at that self pay surgery as their once in a lifetime surgery.

They just aren't paying for repeated surgeries anymore.  I would jump through whatever hoops are necessary to get your revision before your ins co follows the standard policy most are today... one per lifetime.  Make this one right, follow the diet, cut out the white carbs, get to a gym.  It is unlikely they will pay for a 4th surgery down the road.

Hi babygirlinokc I am in the same boat with BCBS Federal they state there is nothing that states that I was compliant with the previous surgery.  The person who submits your paperwork has to be real careful with that issue. Best of luck!

Hi yoyo0212,  Yes, we are in the same boat.  How are things going with you now?  

 

Thanks I appreciate your input.