Blue Cross Blue Shield Of Texas Policy Change 2-1-2012

[mizpk83 9]

Good afternoon,

I had a friend that did not know the policy has changed that she no longer needed the 6 month supervised weight requirement. She is so happy and will be in surgergy less than 2 weeks. If this apply to you please contact your doctor. I am posting information from Blue Cross Blue Shield webiste:

Title:

Bariatric Surgery

Number:

SUR716.003

Effective Date:

02-01-2012

Legislation:

ILLINOIS: None

NEW Mexico: None

OKLAHOMA: None

TEXAS: None FEDERAL (applies to all Plans): None

Contract:

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coverage:

NOTE: Check member’s contract for benefit coverage for bariatric surgery.

PATIENT SELECTION CRITERIA FOR COVERAGE

For a member to be considered eligible for benefit coverage of bariatric surgery to treat morbid obesity, the member must meet the following two criteria:

1. Diagnosis of morbid obesity, defined as a:

• Body mass index (BMI) equal to or greater than 40 kg/meter² (* see guidelines below for BMI calculation); OR
  
• BMI equal to or greater than 35kg/meters² with at least two (2) of the following comorbid conditions related to obesity that have not responded to maximum medical management and that are generally expected to be reversed or improved by bariatric treatment:
  
  • Hypertension, OR
    
  • Dyslipidemia, OR
    
  • Diabetes mellitus, OR
    
  • Coronary heart disease, OR
    
  • sleep apnea, OR
    
  • Osteoarthritis; AND
    

2. Documentation from the requesting surgical program that:

• Growth is completed (generally, growth is considered completed by 18 years of age); AND
  
• Documentation from the surgeon attesting that the patient has been educated in and understands the post-operative regimen, which should include ALL of the following components:
  

1. Nutrition program, which may include a very low calorie diet or a recognized commercial diet-based weight loss program; AND
   
2. Behavior modification or behavioral health interventions; AND
   
3. Counseling and instruction on exercise and increased physical activity; AND
   
4. Ongoing support for lifestyle changes to make and maintain appropriate choices that will reduce health risk factors and improve overall health; AND
   

• Patient has completed an evaluation by a licensed professional counselor, psychologist or psychiatrist within the 12 months preceding the request for surgery. This evaluation should document:
  

1. The absence of significant psychopathology that would hinder the ability of an individual to understand the procedure and comply with medical/surgical recommendations, AND
   
2. The absence of any psychological comorbidity that could contribute to weight mismanagement or a diagnosed eating disorder, AND
   
3. The patient’s willingness to comply with preoperative and postoperative treatment plans.
   

Contraindications for surgical treatment of obesity include:

• Patients with mental handicaps that render a patient unable to understand the rules of eating and exercise and therefore make them unable to participate effectively in the post-operative treatment program (e.g., a patient with malignant hyperphagia [Prader-Willi syndrome], which combines mental retardation with an uncontrollable desire for food).
  
• Patients with portal hypertension, an excessive hazard with laparoscopic gastric surgery.
  
• Women who are pregnant or lactating.
  
• Patients with serious medical illness in whom caloric restriction could exacerbate the illness.
  

[ducker2010 17]

This went into effect the week I finished up my six month visit and got approved! Grrrrrrrr

[mizpk83 9]

Wow...I'm glad I was only 2 months in..how long did it take to get your approval.

[ducker2010 17]

From start to finish...9 months. They said I had to do 6 visits with my doctor. I did and filed. They turned it down because they considered the FIRST visit a consult. So I did another visit and submitted it. They turned it down again because they said the second visit wasn't detailed enough. At that point they got kind of threatening and said if I filed again they were going to withdraw my insurance. That's highly illegal. My husband reported them to the state insurer's board. Then I did another visit (eight in all) and we resubmitted the claim as a new claim. I was approved on my birthday and notified on Friday the 13th! I had my surgery done on January 23rd. It was a long process but totally worth it. I would tell others to keep fighting.

[mizpk83 9]

Thanks for the info... BSBST approved it so it was a 2 day turn around that is awesome. Now I am just waiting on my surgery day.