Question:
Does anyone one have Healthnet Advantage Platinum in New Jersey?
I have Healthnet insurance and they have been great until now. They have denied coverage for the surgery saying that do not meet medical necessity because I did not provide documentation of a 6-month supervised diet in the past two years. I agree that I have not participated in a supervised diet in the past two years, however I have in the past 4-years. My surgeon has been trying to get a peer to peer review with a medical director at Healthnet and they are not returning his calls. I may have to file an appeal to see if they will cover without me doing an additional 6-months supervised diet. Has anyone had deal with Healthnet in this manner. Also if anyone has a sample appeal letter I would greatly appreciate it. — smiller8 (posted on September 14, 2006)
September 14, 2006
Honestly, you're probably going to have to do the 6-mo diet again. And I
would suggest you start it now while you appeal, if you decide to, so you
can start working on it. The reason for the diet is to see if you can be
compliant and possibly lose weight - any amount of weight lost before
surgery is great. It will help with the surgery and healing time. Plus,
it's less you have to lose later!!! Not many people get around this diet
thing and a lot can happen in 4 yrs. Your surgeon should have known you'd
get denied. I have Aetna so I can't help with your specific carrier. Good
luck.
— platypus
September 14, 2006
Sharon,
Ever since bariatric surgery caught on, insurance companies added the 6
month supervised weight loss program. I agree with the previous post that
suggests you start the 6 month program now while you are filing your
appeal. If it is coming upon the time to review your insurance plan with
your company, you may want to switch to an HMO. I'm a paralegal and here
in the State of Maryland if you meet the requirements, basically laid out
by NIH -- then you can't be denied the surgery. I pulled up the state of
New Jersey's website and found this .pdf document.
http://www.state.nj.us/health/hcsa/documents/bariatricsurgeryrpt.pdf
If you are able to switch to an HMO at your company, then do because on
page 35 of this document "HMOs in New Jersey are not permitted to
exclude bariatric surgery." So, if your Healthnet is an HMO, they
can't exlude the surgery but they can make requirements. Some surgeons may
sometime require the patient to loose weight prior to the surgery, so
either way, you may have to do the weight loss program
I live in Maryland and have a PPO, however, the insurance company requests
6 months of supervised weight loss. I don't have to have a referral from
my PCP, but she agreed that I was a prime candidate and she started me on
the six months. I should know either by the end of this week or the next
about approval. I meet all the NIH requirements which are also adopted by
the State of Maryland.
Also, sometimes people don't get approved because of the way the request is
written. If you are using a bariatric clinic, they should know how to
write up the request.
— the7thdean
September 15, 2006
I also had healthnet and they didnot make me do a 6mo. diet, wasn't ever a
question. My bmi was 43.9 and I had a stroke so needed the wls fast. That
was almost 6 mo. ago. Doing geat and no more high blood pressure. Been off
med since the third day after. e-mail if you want.
— momtoall
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