Calling All Bcbs Insured- Bariatric Certification/ Qualification

[feszyk 6]

My coordinator (penn presby) sent my paperwork in to BCBS yesterday. She mentioned some concern over the bcbs requirements for approval- that they required 6 months of a dr. monitored diet. Still waiting.

When I started this process back in February, this requirement was also mentioned. I called BCBS twice back in February, and was pleasantly surprised by the way my call was handled, and the answer I was given; based on the requirements of BCBS and my company's rider, the VSG was covered w/ the only requirements being.

a. BMI >40

b. acceptable physical/psych eval.

Just to be sure, I called BCBS yesterday a 3rd time, actually got over to the 'pre-certification' customer service group, and was forwarded after an initial conversation to a nurse. She gave me the same exact answer after I communicated the p presby coordinator's concerns. BMI and phys/psyc..

I am relatively optimistic that I will be approved, but I am curious if anyone else with Anthem or X BCBS could share their experience and help me set an appropriate expectation..

thanks

[vsgchichi 48]

I have blue cross of CA ppo and they will approve you as long as your BMI is greater than 40 or greater than 35 with at least 1 comorbidity, nutrition consult and psych eval.

[Wheetsin 714]

I was approved through Anthem BCBS. My coverage required a 6 month supervised diet, but since I was a revision the requirement was waived (as would my BMI have been, but unfortunately I was unbanded long enough that my BMI went back up.) Psych approval was also required.

If you're anxious, just get a copy of the rider from your employer. They will have contract changes (riders) on file, surely. You can also compare it to your SPD.

ETA: I also had to do the nutritional class, which for my surgeon is a combo of pre-op education, nutrition, and physical therapy - with a test at the end.

So given that I was a revision, psy approval and education class were my only real requirements. Oh, and my surgery had to be done at a full blown hospital (vs. a surgery clinic), and required an overnight stay (which my surgeon does anyway).

[Liberated Sleeve 148]

Anthem here - psych and dietician evaluation - no waiting period had BMI ove 40 with 3 comorbidities

[cookies 56]

I think with BCBS it depends on your individual policy. I'm with BCBS and they do not pay for any type of weight loss surgery--at all--with our policy.

[jaymzee 79]

I have bcbs and as long as your bmi is 40 or more with comorbities you qualify. You have to have six months of noted weight loss attempt with the doc though. But if your bmi is 50 or greter they will wave that.

[mrsbrown0330 9]

I was approved through BCBS as well, but I had to do 6 months of nutritional dr. visits. I went through allllllllll I was supposed to only to get approved for $5000 LIFE MAX!!! I still would of had to come up with $6000 out of pocket. Well my job changed to United Healtchare in Jan 2011 and I didn't have to show them anything but my approval from BCBS and they approved me in no time...covered at 100% with no max!!!!!!!!!!!!!!!! Make sure you get specifics from you insurance carrier. Just a lil' FYI!!!

[Malyss 31]

I have BCBS NJ Direct and didn't have too much trouble getting approved. I'm not sure how many of my preliminaries were insurance dictated and how many were what my surgeon required, but I had to have a sleep study, upper GI, a visit with a cardiologist, which led to a stress test, a psych eval, and possibly more that I'm forgetting. I also had to attend 3 months worth of my nutritionist's nutrition classes, which included weigh-ins.

Also, my BMI was greater than 50, I had sleep apnea and high blood pressure. So, I had some comorbidities.

[Wheetsin 714]

There are provider requirements, but any employer can customize those. So what Person A had to do to be approved is not necessarily what Person B will have to do. The core requirements tend to follow FDA guidelines for approval. Employers can go more lenient, or strict - depending on their pocketbooks.

You can always just call your provider and ask them the requirements for CPT 43775, for your plan. Make sure to have a copy of your SPD handy.

[Jeni Martin 26]

You can always just call your provider and ask them the requirements for CPT 43775, for your plan.

This is what I did for my BCBS, plus I was told from doctor office that the 6 months was not required by NC BCBS.

[urbandecayno5 40]

I have bcbs and I was approved with just the 6mo diet and letter from my dr. Needless to say I had to still do millions of tests and 3 support groups psych eval..before I could have the surgery(surgeons requirements)..bcbs covered everything

[JaimeC 4]

I have BCBS of Texas and had to go through the 6 month nutritional classes, but thankfully the hospital my surgeon is with offers them. It was very informative! I feel it made me more aware of what I was goi g to go through.

[shortypants 26]

They are all different. I have BCBS of ny, EPO. BMI of 35, with 1 co-morbidity. 1 NUT visit, psy eval, pulmo

[shortypants 26]

oh, and I forgot. I heard back from ins 45 minutes after submission with an approval.

[Jburkley819 3]

I have bcbs NC and I only had to have a bmi of 40 or 30 with one comorbidity, psych eval, and nutritionist visit some blood work and my doctor ordered an upper gi. I was aprroved in 2 days and they cover it 100%!