My referral was denied

Hello,  My refferral to see the Surgeon was denied by BCof CA. I just don't know what to do. They are requing 6 month of mange health. I'm tried everything with no results and I'm just to the point of not know what to do. Can you guys give me some advice???

I have Kaiser insurance in southern CA. They also require a 6 month supervised weight loss program. I had done one for 8 months in 2002, so I met that qualification. I still had to do an educational class of several weeks.  If I had not had the letter about the weight loss program, I would have had to participate in the 6 month program through my insurance company. Most insurance companies do not give you the surgery right away, they have some "hoops" to go through in order to qualify. But the time can be put to good use. Gaining education, attending some support groups for a better idea of what post op life is like, and losing some weight in the process. Most surgeons want you to lose some weight prior to surgery--it helps remove the fatty liver deposits, making LAP RNY easier to do. If the liver is too fatty, the LAP procedure cannot be done, and you may end up with a long vertical scar on your abdomen instead of 5 band aids.

I don't know what all you have done so far or what type of insurance you have thru BC of CA.  I have BC of CA  PPO plan.  Now each PPO plan can be different.  In any case this is what I did.  I had a referal from my PCP with everything noted that would help with the approval.  I gave him every diet I had ever tried and the results so he could put it in his letter.  With that and all the other required paperwork I was approved in 3 days.  I hope that helps just don't give up the fight!!!!

I work for Blue Cross, and I have an HMO with them. UGH long jorney

 I doubt it was BCBS that denied a referal to the surgeon, it was the IPA.  Thats who actually manages you healthcare plan, they contract to BCBS adn your PCP.  I would bet alot of money THEY are the issue. I dealt with the same crap for over a year also in CA also with BCBS as the carrier. With the HMO, BCBS leaves all the decisions up to the IPA to approve or dent the referral. hey have their own requiremnts that could be different that what BCBS requires. Good news is you can appeal directly through BCBS and essentially force your IPA to give you the referral, I had to do this. I had been through hell and back with my PCP and IPA before I fianlly switched to a PPO and was apporved in less than 6 weeks after 14 months of fighting the PCP/IPA for the same thing. PM me and we can chat offline if you'd like. It a long crappy fight that sometimes feels like no one cares but you, just remember you are literally fighting for your life here and keep fighting until you get what you want.

Sorry to hear about your denial as I was also denied initially but by Aetna. I was heartbroken at first but quickly found out everything Aetna required for approval. I made a lot of phone calls to Aetna to figure this out.

The list of things was extensive including the pre-WLS diet and exercise program, history of diets, 5 year weight history and so on. I worked with the WL surgeons insurance specialist and prepared a checklist of all Aetna's requirements. I even called the Aetna MD in Chicago who was in charge of WLS insurance approvals to make sure my checklist was complete and had her tell me "once I have all this stuff and completed the pre-exercise and diet program, I get approved, right?"

I became my own insurance advocate so to speak. Hang in there, find out exactly what they need for approval, then do it.

Boner  

Here's some good info on insurance issues for WLS:

Acquiring insurance coverage for weight loss surgery can be a major obstacle to finally achieving a healthier body and life. Over the past few years, insurance carriers have seen a significant increase in the demand for weight loss surgery procedures. According to the American Society for Bariatric Surgery (ASBS), 16,200 weight loss procedures were performed i***** Ten years later, in 2004, an estimated 140,640 surgeries were projected to take place — that's more than an 800 percent increase! The average cost for surgery is now approximately $25,000. Due to this increase in procedures and cost, some insurance companies are making it more difficult for patients to obtain approval. These insurance companies don't view their policyholders as long-term responsibilities and figure their customers will switch carriers before they can recoup their investment.

So what hurdles will you have to cross? Most companies require what's called a letter of medical necessity from your bariatric surgeon and your primary-care physician. The following information is generally what's required in this preauthorization letter:

• Your height, weight history, and body mass index (BMI)

• A description of your obesity-related health conditions, including records of treatment

• A detailed description of the limitations your obesity places on your daily activities

• A detailed history of the results of your dieting efforts, including medically- and non-medically-supervised programs

• A history of exercise programs, including receipts for memberships in health clubs

Ask your doctor to include information from medical journals regarding the effectiveness of weight loss surgery, especially information demonstrating the control or elimination of obesity-related health conditions.

Many carriers also require a nutritional consult and psychological evaluation. Your surgeon will take care of referring you for these consultations.

A number of carriers now require detailed documentation of participation in a physician-supervised diet. Most require the submission of at least six months' worth of office notes from the supervising physician, including proof of dietary supervision and recorded weigh-ins.

Not all primary-care physicians support weight loss surgery. Your physician may not be up to speed on the latest techniques and safety reports; he may only be familiar with older procedures that had higher risks. Don't be discouraged. You can bring information to your doctor to try to change his opinion. If your primary-care physician cannot be persuaded, you may have to find another primary-care doctor who understands the necessity for your surgery.

Request letters and documentation from any medical professionals who treated you for health-related conditions caused by or aggravated by obesity. Make sure all the letters are sent directly to you (as opposed to your doctor's office), so you can determine if they're supportive of your case. Be sure to make copies of the letters for your records. In addition, forward to your surgeon anything that documents difficulties related to morbid obesity such as:

• High blood pressure

• Diabetes

• Cardiovascular disease

• Sleep apnea

Each weight loss surgeon's practice has its own way of managing financial and insurance issues. Someone in the office should be able speak to you about your insurance concerns and questions. Most of these advisors are familiar with the ins and outs of working with specific carriers.

Being familiar with your own policy is still important. Even the most well-informed advisor won't know all the details of your specific policy without some investigation.

Excerpted from Weight Loss Surgery for Dummies

Just to let you no I had Surgery nearly a year ago . Back then BCBS required a one year diet plan. You will be approved if you stay dilligent.It took me nearly two years to do all their crap but today I'm the better for it.

I have BCBS CA PPO, I had to pay for the initial consult with the surgeon but after that his office took over and the process sailed right through.