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My insurance policy states that my 6 month diet should show a "failed" attempt to reduce the bmi.
Right now at am purposely holding at 40% bmi. I would like to at least lose 10-15 pounds before surgery (hopefully May 2011).
Has anyone been denied because they went below 40%
My co-morbidities are Gerd, Joint pain, family history of diabetes, heart disease and hbp. (mom and sister). I don't have any major co-morbidities and the UHC coordinator gave me a sketchy answer. She said I "should" be ok... Sorry that answer is too vague.
To this point, Tricare has been quite easy.
I'm a 5'9", 33 year old mother of 2 living in Sunny San Diego
Starting Weight: 273 Surgery Weight: 235 Goal Weight: 140 Surgery Date: 08/08/11
Did you get an answer to your question?Ii am in the same situation. I started mt diet January 26..I think my 3 months ends in April but my doctor office states it ends this month.
I am a tricare prime west retiree patient. Have any of you out there been approved for the VSG on Tricare Prime?
I do not, nor can I see the MTF on post, as they do not take retiree patients. They barely can see active duty people. The MTF is not an option for me. My Civilian PCM referred me to a bariatric surgeon and my initial consult is March 16th.
Anyone been through this process successfully?
Thanks in advance!
Amy
Hi Ginger,
I was exactly like you....CRAZY nervous about being denied....and i WAS!! And so was my daughter! But I appealled both times and won the appeal on both. Then, my two sons went through the approval process and they were approved with no problems at all!
I don't have BCBS, I have Aetna. They have a clinical bulletin that spells out the requirements that you need to meet in order to get approved, I printed that and used it as my bible and checklist to make sure everything on that list was covered. I was just like you though...couldn't sleep or think about anything else except scared to death I would get denied.
The reason I was denied is because my surgeon's office turned in my paperwork too soon and I had not finished my physician supervised diet yet! So, I got denied, continued and completed my pcp supervised diet, filed the appeal, and was approved.
My daughter was denied because they said she did not 'show proof of 2 year history of obesity' We put together her appeal by submitting 4 years of office notes from our physician showing her BMI being >40 for four years! She was eventually approved also.
Then, about four months later, my 2 sons information was submitted for approval an they were both approved within a couple weeks with no trouble at all!
I guess my suggestion to you would be to get a copy of your insurance requirements for what you need to do to to get approved, Go over it with a fine tooth comb and make sure you have met all of their requirements and that when you (or your physician or surgeon's office) submit for approval, they have that checklist and all the required information is submitted.
Approvals are usually pretty quick, but if you have to appeal, it can then take up to an additional 30 days and the waiting is nerve wracking!!
Good Luck to you on your approval! Keep me posted!
Nan
Nan
HW 300 / SW 280 / CW 138 / GW 140
Hit Goal 4/2/2010
I can help you! I have Aetna and I had surgery in 2009. I was denied at first and sent in my own appeal and was approved to have surgery. Then, in May 2010, my daughter was denied, I filed her appeal, and she was then approved. In the fal of 2010, both of my sons were approved for surgery and had their surgery in December! Do I have some experience with Aetna, what they are require, and how to file an appeal.
I will send you my appeal letters I used and also a list of what exactly we did to get approved. They have two different routes you can take. The 6 month physician supervised diet and the 3 month multidisciplinary program. Three of us did the 3 mo MD program and my one son did the 6 month physician supervised diet.
It will help me, to help you, if you can tell me exactly what the denial letter said. From what you say, he was denied for exactly what my daughter was denied for (lack of proof of obesity that consisted for 2 years). And is sounds like they are not seeing that he completed the 6 month pcp supervised diet. Did you husband go each and every month for 6 months (seven visits total) over a period of 180 days?? That is what they are looking for. Everything must be documented in the physician notes that he was there for weight loss, his weight, bmi, notes that he was following a reduced calorie diet, exercising xxxx amount of days per week and documenting his behavior modification.
I will PM you!! In the meantime, let me know exactly what his letter says and I will help you put together your appeal.
Nan
Nan
HW 300 / SW 280 / CW 138 / GW 140
Hit Goal 4/2/2010
UHC wants me to start my six month support group requirement over. I complete all of my insurance hoops this week. I think I will submit my paperwork and see what happens. If I am denied how long does an appeal take? I believe my appeal would go faster than five more months of support group meetings. I strongly believe support group requirement should not prevent anyone from having surgery. Any insight please?
Stephanie
LOL I know exactly what you mean! Focus on the prize!! We will do very well I know it.
WE ARE ALL IN THIS TOGETHER! LET'S GET HEALTHY! 
STARTING WEIGHT 211.8, SURGERY 23 MAR 11; ONEDERLAND 30 MAR 11 199.2 
Hockeymom87 · 0 replies · 605 views
