Hello All-
Im a longtime lurker and decided to register and create a thread today... I'm aware all health plans vary however I wanted to put ease in someone elses mind who may have a similiar employer health plan as me. I have Blue Shield of CA Access+ HMOSM Plan 20. When inquiring about coverage for lapband and any and all prerequisites that would need to be completed prior to surgery, this was the response I received:
"Thank you for your inquiry.
Medically necessary bariatric surgery is covered under your
health plan.
Blue Shield will provide benefits for medically necessary
inpatient or outpatient
bariatric surgery procedures to treat morbid or clinically
severe obesity only if:
Performed at designated preferred bariatric surgery facilities
and by designated preferred bariatric surgery physicians that
has contracted with Blue Shield to provide the procedure.
The services are consistent with Blue Shield's Medical Policy.
Prior authorization is obtained in writing.
All bariatric surgery services must have prior authorization,
in writing, from Blue Shield's Medical Director. Prior
authorization is required for all persons.
Non-Preferred Providers are covered only if prior
authorization has been obtain.
The laparoscopic and open adjustable silicone gastric bypass
(Lap Band) procedure is eligible for coverage.
Information needed for review (bariatric surgery):
* Current History & Physical exam (within 6 weeks of surgery);
* Procedure code;
* Patient's current height & weight;
* Patient's age;
* Diet history;
* Contributing medical conditions (diabetes, hypertension,
joint pain, etc.)
* Frame size (small, medium, large);
* Body mass index (BMI);
* Multidisciplinary team consults (medical, surgical,
psychological and nutritional)
* Name of facility where surgery is to be performed
* Patient Address (street, city & county)
* Proposed date of service
The Personal Physician is responsible for providing primary
care and coordination or arranging for referral to other
necessary health care services and obtaining any needed prior
authorization by your Medical Group/IPA or Blue Shield.
Blue Shield covers acute inpatient services provided by a
hospital. Services include general nursing care, semi-private
room and board, and intensive care. Services must be medically
necessary.
Copayment: $1000.00 per admission..
The providers that see you at the facility will be a $0.00
copay. Aldo the lab services are a $0.00 copay per the
benefits on the policy.
The office visists will be $20.00 per visit."
I am actually having my surgeon consult today @ Cedar Sinai. Good luck to all and hopefully this post helped.
