I am devastated!!!

I am heart broken and confused. I applied for medicaid in mid August. They approved and sent me cards. I contacted my doctor's office for WLS. At that time, I had medicaid HMO. The office called for benefits and was told only needed 6 months medical weight loss. In September I got a notice stating that I needed to pick a group. So I chose amerigroup. So come January when my doctor's office was updating everyone's file they said Amerigroup's criteria is different: 2-3 years supervised medical weight loss. I still have medicaid. Why the different criteria?? I had 2 more visits to go to meet the 6 month requirement. I am physically ill hearing about this. Any suggestions??? I am devestated.

 My guess is that you may be able to appeal because when you enrolled the criteria was one thing and then they changed them midstream they may honor the criteria that was in place at the time of your enrollment

OR

You can try to switch to another Medicaid HMO that has the 6mth requirement

I'm sorry you are having so much trouble.  I know how it is to want something so bad and be disappointed.  Luckily in 2003 when I had my surgery, it was just getting started and did not have too much trouble.  Hang in there, don't give up.  While you are waiting, you could try Body By Vi 90 Day Challenge.  It is low in sugar, low in carb, and hi in protein.  It is helping people all over the US lose weight even when they couldn't.  I just lost 11 lbs that I had gained back.  My husband and I are feeling better than ever and are so on it because of the nutrition it offers.  Check it out at mitzitaylor.bodybyvi.com.


Mitzi
Gastric By-pass 2003
Dr. Luis Gorospe, Tulsa OK
224 lbs - now 136 lbs, size 6-8

 Depending on how long ago you picked your group, you may be able to change groups.  They usually give you 30 days to change, then you are stuck for a year.  Managed Medicaid plans are kinda like commercial plans.  They act like Medicaid but are managed by different companies.

Good luck!

Find out about changing plans and if you can make sure you pick one that has the least amount of restrictions for WLS.
Also, with some insurance companies if you show your weight over the last 2 or 3 years, along with notes from the doctor that you discussed your weight and how to lose it, it may be considered supervised weight loss, maybe something like Weigh****chers, too.  Find out exactly what they mean by medically supervised weight loss.

I have worked in hospital billing before and I was wondering if you have tried to switch back to the previous medicaid that you had? Maybe there is another medicaid hmo that has the same criteria of six months medical WLS. I don't know if you would have to wait thirty days before you can change again. I do know that you have the options of changing. Make sure you check with the surgeon's office to see which HMO they except, they should be able to guide you in the right direction.

Thanks all. I am doing some research. The criteria actually says: "Documentation supporting the reasonableness and necessity of the surgery must be in the medical record,and should include a 3 year documentation of medically supervised weight loss and weight loss therapy including recipient efforts at dietary therapy, physical activity, behavior therapy, pharmacotherapy, combined therapy, or any other medically supervised therapy."
Call me crazy...but using the word "should" leaves it open to me thinking you are supposed to have it. But... I think the word "must" is more direct. Do you think I can appeal??? My doc's office said they won't even request authorization without it. Oh...and Nevada puts you in straight medicaid HMO until you pick a group. And both group's criteria reads the same. Yet straight medicaid is just the 6 months.

Im sorry honey thats terrible,i wish you the best of luck i hope everything works out for you:)

Try appealing it. You can always appeal a denial, but make sure you are within the time limit. I recently appealed my denial, and with the proper documentation, I was approved. What happened to me is that the person from my insurance that answered the phone told me I need 6 months supervised. When I applied, they denied stating I needed a year. My denial was the day before the scheduled surgery so I was also devistated. I appealed and submitted charts from my primary care dr that showed i had been seeing him for a year, and they approved. As long as you have documentation, you can possibly overturn this. Good luck to you!

I dont know if you have the same groups that i have in texas but i fought like hell to change my plan and finally got switched to Community Health and they only require a 6 month medical weight loss. Hang in there and good luck!