BlueCross BlueShield Nutritional Eval

mcw12985 · July 30, 2006

Hi Guys,

So I've been on the edge of my seat this week waiting to hear if insurance will approve me. I was told I needed a psych eval, letter of medical necessity from my PCP, to be heavy enough, have 2 health problems associated with being overweight, and I was good to go. Did all that/have all that.

WELL, I just couldn't contain myself and called BCBS SHPS to see how the authorization was going. They said it was pending, but now I need a letter of medical clearance? What the! :Banane56: I guess that comes from my PCP as well. You would think the letter of medical necessity would be enough, that he wouldn't write it if he didn't think I was physically able to have surgery.

Secondly, I have to have a nutritionist eval. What is this!!! :help: I've been looking at the forums and see that people have had to work with a nutritionist for several months before they could even HAVE the surgery!! Very not good, as my husband is joining the Air Force in September and this good insurance will be gone. So what is a nutritional eval? Are some of these only 1-time visits? Please inform me!! I'm soooo nervous right now because I need to get everything done so quickly, but I feel like I keep falling back a step. Please tell me someone else has BCBS and that it wasn't that big of a deal!

Stressing,

Mallorie

Bettina · July 30, 2006

Well, I can tell you from my experience that the letter of medical necessity came from the surgeon doing the lap band. The medical clearance comes from your general practicioner. (cause the lap band doc, if he is a specialist only deals in your weight and co-morbidities, but your GP knows your history so they will be able to tell if the surgery is safe for you.

I had one visit with the nutritionist and still have to attend another one called "Boot Camp" then I can have the surgery )each visit is $250...ugh....then I had to agree to 12 more visits.....mandatory...otherwise I will not get my receipts and then I can't submit them to insurance. My doc is huge on this because the Lap Band is only a tool....it doesn't curb your appetite, doesn't keep you from craving, so he wants to make completely sure this lap band is gonna work.....my sis only had a quicky meeting with the nutritionist and she gained some of her weight back (gastric bypass) On the upside the nutritional Evaul is great! When I left, I was thinking if I get denyied, I will continue with the nutritionist cause I think i can lose the weight just with them!!!! --I too am waiting to hear--just gotta get my apnea machine and i can schedule. Yay.

Oh and I was wondering, why didn't they tell you about these test up front?? My doc told me on the first day....do this, do that...gave me a packet and told me to get it all finished and then we schedule.

To maybe set you at ease, I was just looking at my doctor's website and I stumbled upon all his patients who posted feedback...it gave their date of approval and I would say 98% of them were Blue Cross Blue Shield....not one of them had my insurance...talk about nail biting! Good Luck and let me know how it goes!!!!!

mcw12985 · July 30, 2006

Thank you, Bettina, for your response!

Well, I actually called BCBS before I made an appointment with the surgeon to make sure the surgery wasn't an exclusion on my policy. When I called, I also wanted to know what all I had to do to qualify. They told me the things I listed: Psych eval, medical necessity letter, overweight (obviously), and two comorbid conditions. They didn't mention the nutritional eval.

I don't mind going to the nutritionist, it's just that I have a limited time to get all of this taken care of. I would like to continue seeing one after the surgery, but I can't do several months of it before, because my husband is joining the service in a little over a month.

I'm going to call BCBS back on Monday to see what it is that they expect. Surely if they needed several months to review, they would have told me that when I called. All they said was that I needed a "Nutritional Evaluation." By the way, what exactly is that? What does the nutritionist write that will help the insurance process?

On side note, has anyone seen a nutritionist in Knoxville, TN or in the surrounding area? The surgeon I'm going to is in Nashville, and I already went to Nashville for the psych consult because they work with them on a regular basis. But if I can, I would like to do the nutritional eval here in Knoxville to save a trip. :Banane56:

Bettina · July 30, 2006

I am curious, why isn't your surgeon telling you what is required? They should know what you need and what you don't if they take your insurance. See I checked first to make sure the Doc was covered, then I found out the surgery was covered. So then I went to the doc......and now after all the other stuff I mentioned in my last post...the Doc complies it all and submits everything to the insurance..."This is my patient and this is why I think she needs lap band and here is the test results to prove it" Kinda get it all at once so they can't keep coming back and saying oh by the way one more test. As far as me submitting the receipts for the nutritional evaluation......that is not something usually covered by insurances at all...but my friend told me she just kept submitting it as medically necessary for the surgery and that it should be covered...she told me the third time she submitted it, they paid it in full. So when I get all the receipts they will see it was to my benefit for the education of my post op well being that I did this. I was also told the psych eval wasn't covered either but I guess when they billed me and didn't hear from me, they submitted it themselves...and out of $150 I only owe $30...yay!! In the nutritional eval, they will take your photo, take your measurements, ask you what you eat, what you want to weigh, then they give you info on how to make this work and lastly I have to write down everything I eat all day for 2 weeks...lol I have to fudge it I think because I have been having odd eating habits lately...like only eating once a day. lol. I am in NJ, so things might be different for you...I am sure they are because if you notice from other threads, everyones doc seems to tell them something different.

Keep me posted!!

sleepyjean · July 30, 2006

The medical clearance is usually required just before the surgery. They want your PCP to check you over and make sure you're healthy enough to go through the surgery. In most cases where insurance is covering the procedure, the whole process gets started with your PCP's referral weeks or even months before the actual surgery. People can go through any number of physical and health changes during that period, so it's really important that they check you out and make sure you're still okay and not at increased risk for the surgery.

The nutritional evaluation is a good thing. The purpose is to prepare you for what's to come. In some cases, the nutritionist starts you on a pre-op diet. In some cases, they are doing their due diligence to make sure you understand exactly how the band will impact your eating habits. It is also when the nutritionist educates you on how to prepare for the first weeks and months after surgery (liquid diet, Protein shakes, etc.)