Please read - Need everyones input

Please read the two statements below and tell me how you all read it? I take statement#1 to read that the patient only needs 6 months of dieting in a years time, right? Statment#2 is 12 months of dieting. These statments came from the same insurance company in different letters. Statement#1 The patient must have a consecutive six months of medically supervised weight management within a 12 month period. Statement#2 Documentation of Medically supervised weight management including nutrition therapy, supervised increase in activity, behavioral interventions and maintenance support. We would need 12 months of intensive medically supervised effort.

This definitely appears to be contradictory. The utilization review guidelines may have changed during your appeal. Of course, the less restrictive requirement should be honored.

All I can say is that BCBS of IL is not playing with a full deck . The 12 months of dieting was sent to me as their so called "guide lines for WLS" back in April, 2004 when they changed their dieting from 6 months to 12 months. When they turned down my appeal in October, 2004 they said I must have 6 months of dieting and this came from one of thier medical review Coordinators. This is what they wrote in their letter. >After a thorough review by our Medical Department, we must maintain >our disposition. The patient does not meet the requirements for the >gastric bypass procedure. The patient must have a consecutive six >months of medically supervised weight management within a 12 month >period. Now let's see if I remember right. October 2003 to October 2004 is 12 months. Donna

I fought with my insurance company for over six months on this same topic. My recommendation would be to have your surgeon fight this fight with you. Has his office had this happen before? What is their opinion? Don't hesitate to call the insurance company and ask them what this means--I'd call twice to talk with two different reps (make sure their stories match) because some of them don't know anything! Good Luck!

hi donna i talked to my bc/bs rep. this morning because i got the same denial as you have. i more than medically qualify... what you wrote is translated into this: I had a md doctor supervise me for a year on a low carb diet... because at every visit (1 a month) he didnt write down (SUZANE IS ON A LOW CARB DIET BUT SHE ATE A PEANUT BUTTER AND JELLY SANDWICH ON WEDNESDAY AND I TALKED TO HER ABOUT IT AND SHE UNDERSTAND SHE CANT HAVE THAT ON THE LOW CARB DIET) .... then your doctor didnt write down enough in his dr.'s notes to support you being on a diet... NUTRITIONAL THERAPY-A NUTRIONALIST to put you on a diet. BEHAVIORAL THERAPY- THEY WANT YOU TO GO SEE A PHYSCHIATRIST THAT SAYS YOUR FINE TO GO THROUGH WITH THE SURGERY YOU WONT KILL ANYONE AFTER WARDS. MY FAVORITE IS MAINTENANCE SUPPORT----WHILE YOUR UNDER YOUR 12 MONTH DIET YOU HAVE SOMEONE ( your doctor...) making sure your maintaining your progress... and last consecutive mean they must be together... cant be two months here two months there. hope i helped.. i think im getting me a lawyer. i have bc/bs of illionois and my husbands work there self insured so i dont think im fighting bc/bs im fighting his job... talk about a touchy subject.. good luck donna