Lap band visit records enough for documentation?

[cindy1976]

So like any good impatient wls hopeful I have been nagging my insurance company about a determination on the pre-authorization request to have my lap band removed and revised to a DS. Since my self insured policy says 1 per lifetime I've been awaiting the denial so I can appeal. But when I called today the rep said that while the determination hadn't been entered yet the notes said I would be denied for lack of psych clearance & lack of structured weight loss effort documentation (can't remember the exact wording but it's UHC). But it din't say anything about 1 surgery per lifetime. I know its not final yet nut I'm excited about the idea that this may actually work out without a huge fight.

Anyway, I got psych clearance a few weeks ago, just need to get that to my doctor so thats no big deal. My concern is the weight loss program documentation (at least 6 months). I have 5 years of lap band adjustment visit notes including weight and doctors notes detailing discussions about my weight loss efforts. Does anyone know if that might work?

Or has anyone ever had luck fighting that 6 month requirement?

My insurance is changing to Aetna at the first of yhe year although ill still be on a self funded plan with my company. I'm not sure how it would work out if I had to do 6 months starting now.

Thanks in advance for any help you can offer.

[larra]

I don't know if that will be accepted or not, but it's at least worth a try. What do you have to lose by trying?

Larra

[chicarita]

I hadA etna and they wouldn't budge on the 6 month diet plan. My plan too is self funded. I had band visits which documented my eating for 5 years. They said it wasn't sufficient. So I did 6 months of seeing my doctor every month and weighing in. That they accepted. Ridiculous...

Aetna has very detailed policy bulletins about WLS and their requirements/restrictions posted online. That's the best place to start.

[cindy1976]

Thanks Chicarita! Bummer to hear but eh, about what I expected.

On the plus side I looked at the Aetna bariatric coverage doc and it looks like they'll now allow 3 months on a pre-op program with the bariatric surgeon instead of 6 months weight loss records. Of course being a self funded plan who knows if that will apply to me.

[chicarita]

It applies to all, fully funded and self funded plans alike. Only difference is that your employer can override the policy and eliminate it. But that's good news about the 3 month thing. I screamed and yelled about the 6 month rule and got nowhere. I'm glad they at least cut it in half!

[cindy1976]

So...I have no clue how this happened but I just got word that my surgery was approved! Even the surgeons office didn't know how it worked out. I submitted my 5 years of lap band adjustment records (which did NOT reflect 6 consecutive monthly visits at any point in the past few years) but somehow that was good enough. I've always known I had a guardian angel but wow, just wow. I am SO happy! Can't wait to start my new life!!!

[nyuboi]

Sept 27, 2013 18:22:42 GMT -5 cindy1976 said:

So like any good impatient wls hopeful I have been nagging my insurance company about a determination on the pre-authorization request to have my lap band removed and revised to a DS. Since my self insured policy says 1 per lifetime I've been awaiting the denial so I can appeal. But when I called today the rep said that while the determination hadn't been entered yet the notes said I would be denied for lack of psych clearance & lack of structured weight loss effort documentation (can't remember the exact wording but it's UHC). But it din't say anything about 1 surgery per lifetime. I know its not final yet nut I'm excited about the idea that this may actually work out without a huge fight.

Anyway, I got psych clearance a few weeks ago, just need to get that to my doctor so thats no big deal. My concern is the weight loss program documentation (at least 6 months). I have 5 years of lap band adjustment visit notes including weight and doctors notes detailing discussions about my weight loss efforts. Does anyone know if that might work?

Or has anyone ever had luck fighting that 6 month requirement?

My insurance is changing to Aetna at the first of yhe year although ill still be on a self funded plan with my company. I'm not sure how it would work out if I had to do 6 months starting now.

Thanks in advance for any help you can offer.

I got all my lap-band records showing medical supervision that extends well over six months, and the insurance accepted it just this month. Get every visit from all doctors in writing. The dictation notes from Roslin also helped me. IT looked like I had been medically supervised from numerous sources.

[nyuboi]

Sept 27, 2013 18:22:42 GMT -5 cindy1976 said:

So like any good impatient wls hopeful I have been nagging my insurance company about a determination on the pre-authorization request to have my lap band removed and revised to a DS. Since my self insured policy says 1 per lifetime I've been awaiting the denial so I can appeal. But when I called today the rep said that while the determination hadn't been entered yet the notes said I would be denied for lack of psych clearance & lack of structured weight loss effort documentation (can't remember the exact wording but it's UHC). But it din't say anything about 1 surgery per lifetime. I know its not final yet nut I'm excited about the idea that this may actually work out without a huge fight.

Anyway, I got psych clearance a few weeks ago, just need to get that to my doctor so thats no big deal. My concern is the weight loss program documentation (at least 6 months). I have 5 years of lap band adjustment visit notes including weight and doctors notes detailing discussions about my weight loss efforts. Does anyone know if that might work?

Or has anyone ever had luck fighting that 6 month requirement?

My insurance is changing to Aetna at the first of yhe year although ill still be on a self funded plan with my company. I'm not sure how it would work out if I had to do 6 months starting now.

Thanks in advance for any help you can offer.

The 6 months doesn't have to be while you were insured by Aetna. So if you start it now -- visits with UHC insurance will help too. UHC had also approved my surgery last summer and accepted the lap-band weigh-ins for six plus months. The dictation notes from surgeons really help if they were weighing you each time. I now have HIP. Not my first choice (the plan is a pain in the ass with referrals required and all) but I switched to get coverage with George Fielding and Dr. Herron.

[nyuboi]

Oct 18, 2013 15:40:03 GMT -5 cindy1976 said:

So...I have no clue how this happened but I just got word that my surgery was approved! Even the surgeons office didn't know how it worked out. I submitted my 5 years of lap band adjustment records (which did NOT reflect 6 consecutive monthly visits at any point in the past few years) but somehow that was good enough. I've always known I had a guardian angel but wow, just wow. I am SO happy! Can't wait to start my new life!!!

Exact same boat. I thought I was going to have to appeal it, but the lap records (which also did not reflect 6 consecutive months) worked. IT was years worth like you.