Question:
Problem with insurance

I have now found out that I must have a phyic exam. Plus unless I have had a dr. supervised diet plan in the last year they may not approve. I haven't. I have tried diets he has given me in the past. What should I do?    — DEBBIE A. (posted on November 7, 2003)

November 7, 2003
Ask you PCP to put you on a diet ASAP. Make sure he/she documents it in you chart. Get weighed in monthly. Since you already know you have to wait for a psych evaluation, you might as well start this process in the meantime just in case. I believe with some insurances, you might be able to work around this, but I know with Aetna, if you submitted for approval after this requirement (6 month supervised diet documented in medical records - pcp letter not acceptable) and did not have the diet, you were denied. Some insurances (Aetna was one) will accept weight watchers membership and some other organized "diets" where you attend classes and weigh in on a regular basis. So, if you've done any of those in the past year or so, you could use them. Good Luck.
   — Carolyn M.

November 7, 2003
I have BCBS (POS) I called them and asked them if they covered gastric bypass surgery and they told me yes as long as it was medically necessary & that my PCP referred me to go to this specialist My PCP wrote a letter to Whomever It May Concern that I've tried every possible diet out there annd that since I've been under her care that I've not been able to loose, then she wrote all the medical problems that I have such as: coronary artery disease,sleep apnea & etc... Then I listed some diets that I've been on such as: slim fast,the atkin's diet and so on.... I was on phen-fen for a few months but it was a long time ago & I could not remember the phycision's name.Then I took this letter to the surgeon then when he writes his letter for approval to BCBS he will list that you've tryed various diets & they didn't work. Good Luck! if I can be of anymore help please feel free to e-mail me.
   — dorothyjj

November 8, 2003
I feel for you hon...I had the exact same problem, and no matter what I did, the insurance would not approve until I could show that I had been on a six month dr. supervised diet. So, I began the Seattle Sutton 1200 calorie diet, began water aerobics through the hospital's wellness center, visited with a dietician every 2 months, got psychological counseling on weight loss every month and met with my internist once a month to discuss my progess. I kept a journal detailing all of these visits & my food intake & my exercise dates & my weight loss. I managed to lose a total of 20 lbs before hitting a plateau. At long last my insurance approved the procedure, and my surgery date has been scheduled for January. All in all, it took me 18 months before the insurance approved the surgery. I guess my point here is, don't give up hope...just jump through the insurance's hoops, and once you can prove that you have met every single one of their conditions, they should approve your operation. If they still deny your claim after that, then it is time to check out legal options. I know of several attorneys who specialize in this field. One that I spoke to is Dr. Payam Shayani. Here is a link to his profile: http://www.obesitylawyer.com/profile.htm Hope this helps you.
   — Susan B.