[Niterun]

Hi All,

For those of you who had this insurance requirement, what did you do. I haven't gotten a clear answer from my insurance as to what would satisfy the requirement.

[ragdolldude]

My insurance company wanted a documented, medically supervised wt loss attempt in the previous 5 years. I had that, and provided the documentation, and still had to attend several weeks of nutritional classes. Without the properly documented wt loss attempt, your insurance company probably will insist that you participate is some type of supervised wt loss program for around a 6 month period. This is somewhat typical of many insurance companies. Check with your patient services department of your insurance company for clarification. If you're concerned, I'd make a phone call instead of waiting for a written reply. DAVE

[SarJen01]

I had to pester my insurance company every day for a week until I reached someone who could tell me what the "approved" programs were for the requirement. Keep calling! They should be able to give you the name of the program and a person or office to contact. Don't let them brush you off. Good luck!

[smease]

I joined weight watchers and saw my pcp every month for about 4 months, that was enough for the insurance company.

[Niterun]

The email battle from someone at Medical Mangement in response to my calls and online chats:

The information you're quoting was from a letter received by your
provider from Medical Management. It was a request by MM to your doctor
to provide additional information to TRICARE within 3 days for
determination of services. The letter also asked if you had
psychological testing, Obesity for > 5 years, drug and alcohol testing,
and several other requirement that are necessary to establish medical
necessity. This is standard for anyone requiring major surgery.

The customer service staff can only give you what they can see. The
letter sent to your provider went deeper into the requirements to
establish this surgery as medically necessary.

Ms. Anderson,
Can we please start fresh with this, it seems we are working from two different starting points.

In September I attended a seminar on WLS, at that time I was given a packet of information to read as well as forms to return to surgeon's office. We were also instructed to check our coverage. I did those things and found that I fell into the general criteria listed. I had recently had some of the testing done for my PCP and had that information forwarded to the surgeon. When I had not heard anything from his office I called to discuss next steps. I was not able to contact the person who handles this and it was a week before she returned my call. At that time she reluctantly gave me info on the program and class fees that were over $700 excluding the 6 month Nutrition class.When I asked about the 6 month requirement, was it something my PCP could oversee I was told no, but I could do the class they offered at $300. I just wasn't sure if she was pushing something for her office that I could get somewhere else. She was not willing to explain to me how all of these things came together, stating that my first consult would cover them. That happens to be a 3 hour group session of about 20 people early in Nov. Since I wasn't comfortable with this I continued to research for another surgeon close by with a friendlier staff and more experience.

I found BluePoint Surgical Group, they are a Center of Excellence, and had a long conversation with the program coordinator. She was very forthcoming and pleasant with information. The fees are about the same but explained and she passed on my insurance info to that coordinator saying I should hear from her by email later in the day or early the next. She also told me that what I can be told when speaking with customer service is not the same as the information that is passed on to a provider.

This was the response from the insurance coordinator:

Marla states she has spoken with you and you're interested in knowing the requirements for surgery.
Tricare Standard does not precert, which means they will review your file for medical necessity once they receive the bill, not prior too.
The criteria requirements are as follows:

1. a 6 month structured weight loss program
2. Lab results from: Hpylori, TSH level
3. Pulmonary clearance
4. Cardiac clearance
5. Psychological evaluation
6. Nutritional evaluation

Once we have all of the above information in your chart, then we may discuss scheduling surgery.
I do understand there is some confusion that when you call them you may get a customer service rep that will tell you nothing is required.(THATS NOT TRUE)
Healthnet happens to be the reviewer for Tricare and I have 1 person there as a point of contact for tricare and she agrees that she can't understand why patients are told this but there is nothing she can do but report it each time she's told and reiterate the above requirements

This was my reply to her:
Thank you for the quick response! I am ready to do this so please explain what type of program I need to look into. Are we talking Jenny Craig, checking in with my PCP every month where we discuss what I'm doing about the weight or under a dietitian with set menus and journals?

Her reply was:
It can be as easy as any of those you mentioned, what they state is, it has to be a structured program ie: you have to physically walk in a center (office) someone to counsel you about weight as well as weight documentation 1 time a month for 6 months.
If you've not completed a program already, I'd suggest going where it will be the cheapest for you. I think Weight Watcher is fairly inexpensive, not sure about your PCP or a dietician.
Lastly, for patients who've had a consult with us, we offer a 6 month WL program, the fee is 300.00 which runs about 50.00 a visit. This would be in addition to the fees Marla discussed with you earlier.



So with this information I attended their seminar on Sat. to have a chance to meet some of the staff. That packet listed the TRICARE requirements for WLS as follows:

BMI OF 40 and above OR
BMI OF 35-40 with life threatening co-morbid conditions
AND
1. Cardiac Clearance (does not have to be from a specialist)
2. Pulmonary Clearance (does not have to be from a specialist)
3. Lab results of TSH level & H-pylori
4. Nutritional eval
5. Psychological evaluation
6. 6 month Structured Weight Loss Program

I met with one of the surgeons yesterday and he said I met the requirements and that my paperwork would be submitted to TRICARE and I would hear from his office in about 2 weeks. I was confused and wrote the following to the insurance coordinator:
Hi Ruth,(Surgerons office)

I met with Dr.Tran today and he surprised me by saying that my case would be submitted to TriCare. Since I have the info you provided last week I was under the assumption that noting would be submitted until I met the requirements. Since I was wrong in that would you please explain to me (again) what I need to get done. I attended the seminar on Sat. and have the following information from the packet:

1. Cardiac Clearance
2. Pulmonary Clearance
3. Lab results of TSH level & H-pylori
4. Nutritional eval
5. Psychological evaluation
6. 6 Month Structured Weight Loss Program

I deleted the answer you gave me so please work with my slowness on this one. Within the last month I have had an Eco and chest X-Ray done to check for damage to the heart & lungs from Chemo. They both were good, would they need to be repeated? Further, if the structured program and Nutritional eval are required for the surgery, will or can your office put in for preapproval of the dietitian? Healthnet suggested to me that it does sometimes cover the service when there is a request made for preapproval from the surgeons office.

Thank You
Jardenia


Her responseSurgerons Office)
Our doctors know minimal when it comes to insurance, the info that you quoted in the current email is true and still stands.....Tricare standard-no pre approval, as previously discussed.
As far as tests already performed, the rule of thumb is.....xray reports, EKG, specialist evals___good for 3 months from the test date.

She really didn't answer my questions so I turned to you guys for some clarification. I don't know who I spoke with on the phone but you may be able to check the logs of the online chat I had with cs_khateryn_p where I am told that if the classes are required for the surgery then they would be covered by TriCare and all my PCP had to do was submit the request. Or that if I paid out of pocket I would be reimbursed.

At no point has anyone told me that Medical Management had sent a letter to my provider about me so I can't quote from it. Especially because at this point I don't really have a provider. I attended 2 different seminars and provided medical information to both who have told me NOTHING would be submitted until I had met all of the requirements for surgery.

Where do you guys think this will end. The way I read it is that TriCare does not require the 6 month program, it seems the surgeon is trying to get me to sign on with him for the money. I feel that if he requires this he should tell me what will meet the requirement, wheather or not I can see someone else or only his people.

[Queenofthenile]

The only thing I had to do was have my PCP write a letter stating all the methods of weight loss that I have tried and failed at. I hope you get the answers you are looking for.