Blue Shield of CA - *** approval requirements

[rdt210 82]

Hi all,

Thought this might be helpful for anyone with Blue Shield of CA - just got this straight from the insurance company about what is needed for approval.

This is by far the most frustrating part of the process...

Anyway, I thought it was interesting that they will accept documentation from Weight Watchers and other programs as long as there is documentation for 6 consecutive months and they occured within the past year and a half.

Good luck to everyone dealing with insurance!!

The following bariatric surgical procedures are considered medically necessary when meeting the criteria listed below:

. Open or Laparoscopic Gastric Restrictive Procedures with a Roux-en-Y Gastric Bypass up to 150.0 cm

. Vertical Banded Gastroplasty

. Laparoscopic Adjustable Gastric Banding (LAGB) (e.g., LAP-BANDR, REALIZET)

. Biliopancreatic Diversion with Duodenal Switch (BPD/DS) for patients with a BMI >/= 50.0 kg/m2

. Sleeve Gastrectomy

The above bariatric surgical procedures are considered medically necessary as a treatment of morbid obesity when all of the following criteria are met:

. Body Mass Index

ο Adults (>/= 18 years of age) (one of the following)

BMI >/= 40.0 kg/m2 *

BMI >/= 35.0 kg/m2* and <40.0kg/m2* with at least one significant obesityrelated disease complication which has failed to be controlled with medical management including, but not limited to:

ο Type 2 Diabetes Mellitus

ο Hypertension

ο Coronary Artery Disease

ο Obstructive sleep Apnea

. Continued obesity despite trials of weight loss through lifestyle changes, diet modification and exercise evidenced by all of the following:

ο Documentation of prior weight loss attempts without successful long-term reduction

ο Documentation of active participation in a non-surgical weight reduction program supervised by a registered dietician, healthcare provider (e.g., physician, nurse practitioner), or an organized weight reduction program (e.g., Weight WatchersT, Jenny CraigT), for at least six consecutive months occurring within the last 18 months prior to the request for bariatric surgery.

ο Monthly documentation of all of the following weight reduction program components:

Weight Dietary regimen, which may include medical nutrition therapy (e.g., MediFastT and OptiFastT) or a recognized commercial diet-based weight loss program (e.g., Weight WatchersT, Jenny CraigT, etc) Physical exercise unless medically contraindicated.

Behavior modification or behavioral health interventions

. Bariatric surgical consultation and recommendation by a trained and experienced bariatric surgeon associated with an institution that supports a comprehensive bariatric surgery program, which includes all of the following:

ο Psychological evaluation and clearance for bariatric surgery

ο Nutritional evaluation

ο Long-term monitoring and follow-up post surgery

Note: A physician's summary letter is not sufficient documentation of active patient participation in a non-surgical weight reduction program. Documentation must include medical records and/or diet or weight-loss logs, and assessment of the patient's progress throughout the programs course.

*BMI >/= 50.0 kg/m2 for Biliopancreatic Diversion with Duodenal Switch (BPD/DS) .

[lahdeedah 3]

Thank you so much for posting this. Everyone I talked to at Blue Shield was no help and none of them was able to give me details, It was quite frustrating. Thanks again