Question:
How is this legal?

BC/BS has now decided that for WLS to be deemed medically necessary, you have to have been on a doctor-supervised diet for the 6 months immediately preceeding the procedure! How is this not discrimination?!? Do people needing gall bladder surgery or a hysterectomy have to wait 6 additional months from the date the surgeon feels the procedures are medically necessary for the insurance to approve? What next!!    — tonib (posted on February 9, 2005)

February 9, 2005
It seems to be a common requirement. If it were me, I would get to my pcp as soon as possible and get started on the diet, and follow up , You could be in surgey by August. Or you could be still fighting with the insurance company in August, Only you can decide which is the better use of your time and resources. So many have insurance with exclusions that will not cover WLS no matter how medically necessary it is. the doctors view of medical necessity may be different than the insurance companies and they do not have to pay anything that does not fir their criteria.
   — **willow**

February 9, 2005
Most insurance companies have a minimum 6-month doctor supervised diet, if not longer. My insurance required that of me, as well as medical records proving a 5-year history of obesity. I've read other members here say they have to have 12 months of a doctor supervised diet. If I were you, I would go ahead and get that diet started... insurance companies usually don't budge on their requirements. Good luck!
   — Shayna T.

February 9, 2005
Not all BC/BS policies have this requirement but I keep hearing it come up more and more. This has been a requirement with many insurances for about 2 years already. I guess I can see their point. They want to be sure that a "proper" diet and exercise program won't produce the results. The bottom line is they don't believe in the "fad" diets, which in their mind is anything a doctor did not prescribe. However, my husband is in the stages of thinking about WLS and is trying to do it the old fashioned way as surgery scares the crap out of him. He only needs to lose about 80-100 lbs. His main reason for even considering it and why I'm sure he would be approved if he went forward is he has uncontrolled diabetes and significant sleep apnea and high blood pressure. His internist, which is the same as mine, has put him on an Atkins type diet because he did manage to lose 30 lbs a few years ago and keep it off doing Atkins. So he figured lets go with what works. Unfortunately he isn't seeing as good of results this time, but at least it will be documented as he's been followed by a dietician at the request of our doctor. The minute he starts eating carbs again he's gaining back to where he was. We all know that in 99% of our situations, the problem is less about losing and mostly about keeping it off. I managed to loose about 200 lbs 9 years before WLS, but it found it's way back. <p>Like the others have said, it's not worth fighting about. You are likely not going to win and then would still need the 6 months or worse yet you are too close to the end of the year and cannot get your 6 months in before 2006 and they decide for 2006 they won't cover WLS. It's a big gamble over 6 months in my mind. I know I would have been disappointed if I would have been delayed 6 months but think in reality I would have met their qualifications. The 200 lbs I lost, while not doctor supervised technically, was documented in all of the doctors office notes because I came up with so many other medical problems. Then the year before WLS I had tried Xenical for a few months and also Wellbutrin to try and curb my appetite, neither of the last 2 attempts producing more than a 10-15 lb loss, and at 442 lbs, that peanuts. <p>Maybe you can get started with some of the other requirements your surgeon has like psych eval, sleep apnea test, etc. during this time so that once the 6 months is up you can head to surgery quickly. Just a thought.
   — zoedogcbr

February 9, 2005
I had Blue Sheild nd they required this of me also. My bariatic doctor had a WL clinic so I just went to them. I felt stupid because I did !Not! lose any weight but I had to play the Insurance game. They also required a session with the psychiatris.
   — Kathleen M.

February 9, 2005
You are confusing the gall bladder and hysterectomy sugeries with an elective procedure, WLS. Many insurance companies are now requiring the 6 and I have heard with some BCBS policies a 12 month doctor supervised diet try. The insurance companies are making sure that the person has made EVERY attempt to try and loose weight on your own. WLS is a very expensive procedure (can have expensive complications also), with expensive follow-up care. You see there have been so many people that flocked to doctors for this procedure that they have to make sure that the WLS is the last ditch thing for a person. So, yes this is legal and be happy that your insurance company covers it even with a 6 month supervised diet try. Christine :)
   — ChristineB

February 9, 2005
I am on the insurance companys side...This is a drastic procedure, and I can personally testify to it..I am a 48 year old femeale who plumpented to 390lbs....I would rather stay at that weight than go thru the MAJOR complications of WSL...I had to have 7 follow up sugerys in the past 2 years..lost 190 lbs,but the burden on myself, my husband and my children was/is unbearable....Try to make this the last resort....go swim..go walk..go bike ..lose a lb a week (that's 52lbs) in one year...Good Luck
   — irene B.

February 9, 2005
I am also of the opinon that this in not a horrible thing to ask of someone seeking this surgery. Look at it this way....It usually takes longer than 6 months from the time you contact a surgeon to the time you have surgery.
   — RebeccaP

February 9, 2005
I am getting ready to see my PCP on Monday and I do have Blue Shield/Blue Cross. I can hardly wait to see what "requirements" are needed before approval. So, what happens if the doctor puts you on a diet and you do lose weight? Will they deny you surgery then?
   — Debbie M.

February 10, 2005
I think that BC/BS is making sure that the surgery canidates that they are appoving are serious. The surgery alone does not make you thin. You have to be willing to make a lifestyle changes and if you are not willing to do a supervised diet for 6 month, what are you going to do after surgery? You do not have the surgery and go on your way. You have to make allot of lifestyle changes. I know that it is diffecult to wait, but believe me, it is worth every minute of it. The surgery is a tool to help you lose weight. Follow the rules and you will succeed. Don't and you are right back where you started, only worse. BC/BS is not the only insurance that does this. I know that Cigna does the same thing. I don't know that this is a bad thing. Hang in there, and start learning some nutrition while you are waiting and you with have a happy, healthy life. Good Luck, Judy
   — jk_harris

February 10, 2005
I also have BCBS, and at first was a bit dismayed at the thought of a 6-mo diet and history. BUT... by the time I had completed all of my tests, probes, x-rays, etc. from other specialists, I had only about 3 more months to go w/my doc regarding those diet visits. It isn't a long time at all. BCBS wants to see that you are trying to lose the weight...even if it doesn't happen...I ended up GAINING SIX pounds in one month, and that about knocked me over! What BCBS also asked me for is a FOOD DIARY, (they were going to deny me), but I actually had a health/diet journal which I had kept for 2 years. So, once they saw this, they approved it immediately. I would wholeheartedly recommend to anyone to keep a food diary (mine was not even a daily diary, but about 3-4 days a week). Also, I included how I felt each day, physically. As I am diabetic, have some sort of chronic fatiguish disorder, chronic pain in muscles, I did do that. I believe that this was the clincher in the approval. Be patient...it'll give you time to get your "ammunition" in order. Best Wishes!
   — [Deactivated Member]

February 10, 2005

   — [Deactivated Member]

February 10, 2005
I would suggest that you get to your PCP and get your weight documented. Also, state to the doctor "I am dieting" If it was not for a WLS friendly PCP and all the help he gave me jumping through the hoops, I would be on my THIRD denial, instead of almost 2 months post surgery and down more than 40 pounds.
   — yvonne1953

February 21, 2005
I have bc/bs for my hospitalization coverage. I work for NY State and the bc/bs is only for hospitalization for me. However, they do require 6 months of supervised diet with your doctors. To meet this requirement, I have to go to my dr monthly for weight checks and go to the bariatric center once a month, plus I have to keep a daily diary of what I eat and drink and how I feel after each meal, as well as how long it takes me to eat.
   — mzb2u

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