does anyone know if pacific care hmo cover revision???
Hello Everyone! Can someone point me in the right direction?? I had surgery 2002 weighing 267 LBS at time of surgery at UCLA. I lost 100 lbs, and was extremely happy and healthy. Well to date, i have gained most of my weight back, weighing 250 lbs. My tReating doctor has been giving me the run around. Until today! She is finally going to begin the process for a referral. Although she states there has never been any approvals out their office.WELL THAT IS SCARY!! Also states she feels it will be denied and doesnt understand how i gained the weight. HMMMMMM that magic question. She kept tell me the whole time, not to get too excited because it will most likely be denied.
HAS ANYONE BEEN APPROVED from Pacific Care HMO??? What happens next after the referal? If i am denied, should i just give up? It took me a year to convince my doctor to provide me a referal. SORRY FOR THE MANY QUESTIONS!!
HAS ANYONE BEEN APPROVED from Pacific Care HMO??? What happens next after the referal? If i am denied, should i just give up? It took me a year to convince my doctor to provide me a referal. SORRY FOR THE MANY QUESTIONS!!
I had an RNY in 2002 and have also gained my weight back. I also happen to have Pacificare HMO and here's what their policy says:
12. Morbid Obesity (Surgical Treatment) Pacifcare covers bariatric surgical procedures hen Medically Necessary and preauthroized. PacifiCare will use scientifically valid, evidence based criteria to determine coverage of bariatric surgery, such as the most recent National Institutes of Health (NIH) guidelines in determining the medical necessity of requests for surgical treatment for morbid obesity. Please refer to your Schedule of Benefits for copayment information of this benefit or you may call PacifiCare's Customer Service Dept. for additional information. Under the heading of Exclusions and Limitations of Benefits 5. Bariatric Surgery - Bariatric surgery will only be covered when Medically Necessary for the treatment of Morbid Obesity. Pacificare will use scientifically valid, evidence-based criteria to determine coverage of bariatric surgery, such as the most recent National Institute of Health (NIH) guidelines, in determining a medical necessity of requests for surgical treatment for morbid obesity. PacifiCare evaluation encourages a multidisciplinary team approach that includes medical, surgical, psychological, and nutritional expertise for those who are seeking surgical weight loss. After surgery the Member participates in a multi disciplinary program of diet, exercise and behavior modification. Surgical treatments for morbid obesity are services related to this surgery and are subject to prior approval by PacifiCare's Medical Director or designee and are limited to one (1) procedure per member's lifetime except as approved by Pacificare's Medical Director or designee when due to medical or surgical complications, it is Medically Necessary and not as a result of non compliance. Please also see "Weight Alternation Program (Inpatient or Outpatient").
Sounds to me it has to be because of mechanical failure, but it's a bit vague. I'm prepared to fight it if need be. I want to revise from RNY to DS. The docs they list in my area only seem to do RNY.
12. Morbid Obesity (Surgical Treatment) Pacifcare covers bariatric surgical procedures hen Medically Necessary and preauthroized. PacifiCare will use scientifically valid, evidence based criteria to determine coverage of bariatric surgery, such as the most recent National Institutes of Health (NIH) guidelines in determining the medical necessity of requests for surgical treatment for morbid obesity. Please refer to your Schedule of Benefits for copayment information of this benefit or you may call PacifiCare's Customer Service Dept. for additional information. Under the heading of Exclusions and Limitations of Benefits 5. Bariatric Surgery - Bariatric surgery will only be covered when Medically Necessary for the treatment of Morbid Obesity. Pacificare will use scientifically valid, evidence-based criteria to determine coverage of bariatric surgery, such as the most recent National Institute of Health (NIH) guidelines, in determining a medical necessity of requests for surgical treatment for morbid obesity. PacifiCare evaluation encourages a multidisciplinary team approach that includes medical, surgical, psychological, and nutritional expertise for those who are seeking surgical weight loss. After surgery the Member participates in a multi disciplinary program of diet, exercise and behavior modification. Surgical treatments for morbid obesity are services related to this surgery and are subject to prior approval by PacifiCare's Medical Director or designee and are limited to one (1) procedure per member's lifetime except as approved by Pacificare's Medical Director or designee when due to medical or surgical complications, it is Medically Necessary and not as a result of non compliance. Please also see "Weight Alternation Program (Inpatient or Outpatient").
Sounds to me it has to be because of mechanical failure, but it's a bit vague. I'm prepared to fight it if need be. I want to revise from RNY to DS. The docs they list in my area only seem to do RNY.
SW 358/CW 201/Goal - anything below 160
Angel to TEAZ (Michelle) 
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