Criteria

[Jennie1980]

My insurance is BlueCare TennCare, Tennessee's medicaid. Actually it's my secondary. My primary excludes. Next week is my 5th supervised diet visit with my PCP. I've completed everything else. I meet all of their criteria except the need for the 5 year weight history showing morbid obesity.

I gained more weight after having thyroid disease. That pushed me to 35.3 BMI. Well that and other things. I've never been thin but it's been a long time since I've been as heavy as I am. 5.3, 199lbs.

I'm seeing Dr. Boyce in Knoxville TN. His office person is pissing me off.

I just found this 5 year requirement. I have contacted the office and told them more than once that my PCP doesn't speak English as a first language and communicating insure required verbage is like pulling teeth. I asked the authorization person to look over a recommendation and clearance letter that I've written for my PCP to put on letterhead and sign.

Instead of responding to me, they faxed my PCP a template. So I called them and explained the language barrier again. Discussed the five years of morbid obesity history. I was told we will submit and see. I'm not ok with that. She said the PCP can be very basic blah blah.

I disagree that basic will help a thing. I'm going to need a really strong letter to hopefully over power this one issue.

I'm sick. I'm in pain. I don't have time for an absolutely unnecessary fight if an appropriate letter can prevent that. She doesn't appear to give a shit.

May be important to add that I can switch to United Health Care on July1. Apparently they're much easier to deal with. But if this is a TennCare rule, doesn't matter which insurance provider I have through them???? I will post my letter below. I'll be happy to answer or clarify anything. I'd appreciate any and all thoughts on any of this.

 

[Jennie1980]

Regarding Jennifer L. Holt Date of Birth: -1980 referral for Biliopancreatic Diversion with Duodenal Switch Bariatric Surgery

Dear Sirs,

I am recommending and clearing Jennifer Holt for evaluation and consideration for Biliopancreatic Diversion with Duodenal Switch Surgery procedure as it is medically necessary for her.

I have been Jennifer's primary care physician since 2015. During that time I have supervised several of her diets, nutrition and exercise program attempts (details listed below). None of these have resulted in any sustained weight loss. She currently weights 199 pounds. She is 63 inches tall. Her BMI is 35.3. She has multiple comorbidities related to her morbid obesity, including but not limited to the following:

1. Obstructive Sleep Apnea Syndrome. This condition can be expected to improve or resolve with substantial weight loss.
2. Hyperlipidemia, not fully resolved with medication. This condition can be expected to improve or resolve with substantial weight loss.
3. Musculoskeletal Disfunction, impairing her daily living and resulting in chronic pain. She has joint pain in the knee, feet and ankles. She has arthropathy. She has back pain and hip pain. She has fibromyalgia. She has Sjogren's Syndrome. Many of these conditions can be expected to improve or resolve with substantial weight loss.
4. Impaired Fasting Glycaemia. Currently controlled with Metformin. This condition has a likelihood of resulting in type 2 diabetes mellitus. This condition can be expected to improve or resolve with substantial weight loss.
5. Hypertension not yet resolved by medication. This condition can be expected to improve or resolve with substantial weight loss.

Jennifer has tried to lose weight under my supervision. However, the following non surgical methods have failed to produce sustained weight loss:
1. Calorie and Carbohydrate Counting
2. Walking
3. Utilizing Home Exercise DVDs.
4. Mediterranean Diet
5. 1800 calorie diet
6. 1200 calorie diet

Jennifer has difficulty exercising because of inflammatory arthritis. These non surgical methods have been unsuccessful in treating Jennifer's morbid obesity or the comorbidities related to her obesity. I am recommending Biliopancreatic Diversion with Duodenal Switch Surgery due to the expected long term benefits for Jennifer's weight loss and comorbidities improvement.

Sincerely,

 

[Jennie1980]

* deleted double posted thread

 

[Larra]

I would suggest separating out the weight related comorbidities (which is almost everything) from the non-weight related (Sjogren's), which is not going to improve with surgery and/or weight loss.

I think overall this is a good letter for a pcp (better than most) but that it won't be sufficient, and that you will also need to request that Dr. Boyce send in a LOMN for you. There are others here who actually know Dr. Boyce, and can speak to how willing or unwilling he would be to do this @southernlady and others will hopefully chime in.

What often happens is that if there is even the smallest technicality that the insurer can use to justify a denial, they will use it, so I don't know that any letter(s) will make a difference. If you haven't already, get your hands on your EOC (evidence of coverage) to see not only all the details of what is required to get approval for bariatric surgery, but also what your appeals rights are, if any, because you may well need to know.

 

[Jennie1980]

I spoke with Southernlady yesterday.

The reason I included the Sjogren's is because it's attack on the joints, which is my only symptom right now, praise God, is considered musculoskeletal, which is one of their comorbidities. If it's better exclude that rather than trying to explain that to insurance people who may have no clue what it is, I will. All my information on Sjogren's that my rheumatologist sends, comes American Arthritis Foundation.

LMON is Letter of medical necessity?

I'll call BlueCare again today to try to get the EOC. Like pulling teeth. Different story every time as to why I can't have it. Last reason was: you must be turned down first.

 

[Larra]

Do include the Sjogren's, just not as a comorbidity. The reason being that weight loss won't help get rid of it. But you can certainly say that along with the other joint problems, this further affects your joints and impairs your ability to exercise.

Yes LOMN is letter of medical necessity.

Keep trying on the EOC. that excuse is BS.

 

[Jennie1980]

Today's response was: you can't have that information unless your doctor has already submitted the request. I'll call again. I'm dedicated to this. I've worked to hard to let 5 years ago effect what I'm living with today

 

[Munchkin]

Be strong and don't give up. Keep fighting. Those insurance companies KNOW your morbid obesity is not going away. But their best hope is to throw so many roadblocks in your path that you will give up.

Shouldn't anyone covered by the policy be entitled to access the EOC? I thought you were but I could be wrong. @DianaCox who is entitled to see the EOC?

 

[DianaCox]

I had to call the Dept. of Managed Health Care/CA Dept. of Insurance to force a couple of insurance companies to release their EOCs. Call your state Dept. of Insurance and tell them that your insurance company is refusing to provide you with a copy of the contract that you are paying for coverage under.