Anthem BCBS Missouri req's?

[goregalore 16]

Hey guys, been lurking on the boards for a couple years and I'm looking for some info. Quick rundown...

Banded 2010 with BCBS, required me to do NUT/psych, doctor letter, and information seminar. Lost 25lbs, got fills monthly for 2 years...nothing. Surgeon said I developed an "intolerance" to the band. Okay? So I got a complete unfill in 2012... fast forward 2 years later and I'm still having vomiting issues and things get "stuck" frequently, my BMI is over 40. Talked to my surgeon on Dec 1st about a revision, which he doesn't do, so I was referred to another surgeon.

Have an appointment pending for new surgeon but in the mean time, I checked BCBS revision requirements and it must have changed since I looked into it 2 months ago. Now it says:

"The individual must have serially documented active participation in a non-surgical weight reduction regimen for at least 6 continuous months, in the 2 years prior to surgery, to enable both behavioral changes and adequate assessment of anticipated postoperative dietary maintenance. These efforts must be fully appraised and documented by the physician requesting authorization for surgery"

What exactly does this mean? I have records from like MyFitnessPal, MapMyRun, a Couch-2-5k app, my surgeon's records of weights and fills from 2010-2012... but I haven't seen a PCP regularly for several years. Would any of these personal records count? Or am I going to have to do a 6 month PCP diet?

I'd like to go into the appointment with documentation if I have it available. Thanks for any info you guys have!

[GADeltaDawn 14]

I've been trying to find out the same thing! This wording just changed a couple of weeks ago. I also have this same insurance and have called 3 times, spoken with 3 different people, and none of them will tell me exactly what this means including the precert rep. I'm told the surgeon will have to request the guidelines. My appointment with the surgeon is February 5 so I'm hoping to get clarity on this. I also have personal records with LiveStrong and weights from my PCP but no kind of doctor supervised diet. I'll post whatever I find out after my appointment.

[PearlyQ 0]

I was glad to find this thread. I've been wondering about this too. My doctor's office called Anthem the first part of January and they were told there is no requirement for a 6-month regimen. I called a few days ago and was told the same thing. Afterwards I stumbled across this policy revision on the Internet, and now I'm worried I will have to wait 6 more months for surgery. I have asked my surgeon's office to contact Anthem again about this. Will post again once I hear something back.

[goregalore 16]

I actually had my first consult last Wednesday. The six consecutive month non-surgical weight attempt was actually taken care of between my psych evaluation and my chat with the nutritionist. I discussed and they documented the different "fad" diets and weight loss attempts I've tried and failed at and that, apparently, is good enough to satisfy the insurance requirements. I do have to go through many pre-op tests but I believe that's because I'm band to sleeve revision. Good luck both of you!

[GADeltaDawn 14]

Oh good! I've tracked my weight in LiveStrong and followed their program so I have 2 years of weight tracking along with my laundry list of other attempts during that time. All my doctor weights correspond to my records so I was hoping this would be enough. My doctor did prescribe me wellbutrin for stress at work in hopes it would also work for weightloss and I've been on that for a year and a half. This med is used for that and my dad actually did lose a lot of weight with it. I only lost like 10 pounds when I first started it though. I'm still taking it but only because it works so good for stress. Trying to make sure I have all my records in order so I'm not having to guess and estimate at my surgeon visit. I go on Thursday. I've already scheduled my pulmonary, psychology and nutritionist and will have all those completed by the 19th. I'm hoping I can get the surgery sometime in march. I'll update after my appointment too. I'm told this insurance is actually one of the easiest to work with

[goregalore 16]

I went into my consult with about 20 pages of past weigh ins, graphs, and whatnot from my own personal apps and MyFitnessPal, etc. They didn't even want to see them... I just verbally went over the diets and exercise regimens I had previously tried, the gym memberships I've had, the 2 years of fills I had with my Lapband, and they said I was set and that's all the insurance really requires. I do, unfortunately, have to go through several pre-op tests other than the normal psych/NUT visit which I knocked out the same day (esophageal manometry, EGD, upper GI, chest x-ray, EKG, thyroid-specific blood tests... I think that's it, lol.) But I think that's surgeon specific and because I'm a revision. Keep me updated with your journies, ladies!

[PearlyQ 0]

My surgeon's office called Anthem again, and spoke with someone in the department that does the surgery approvals. They confirmed that the policy change will apply to me, and that I will have to go through 6 months of medically supervised dieting. Ugh!! Very disappointed as I was looking forward to having surgery in March or April.

[GADeltaDawn 14]

OK, so I had my appointment with the surgeon today and have no supervised diet with Anthem BcBs. I've gotten clearance from my PCP, pulmonologist, and my labs are done. Next week I have my psychological exam and the following week I have the nutrition class. Once everything is completed I'll have another appointment with the surgeon, dietician and an upper GI. I'll sign my paperwork at that visit. 5-10 days later my insurance approval will come in then I get a surgery date. What a whirlwind the past two weeks have been! In all actuality I may have my surgery sometime in March! So excited to have my hope back!

Edited February 6, 2015 by GADeltaDawn

[melissagnizak1970 1]

Hey guys, been lurking on the boards for a couple years and I'm looking for some info. Quick rundown...

Banded 2010 with BCBS, required me to do NUT/psych, doctor letter, and information seminar. Lost 25lbs, got fills monthly for 2 years...nothing. Surgeon said I developed an "intolerance" to the band. Okay? So I got a complete unfill in 2012... fast forward 2 years later and I'm still having vomiting issues and things get "stuck" frequently, my BMI is over 40. Talked to my surgeon on Dec 1st about a revision, which he doesn't do, so I was referred to another surgeon.

Have an appointment pending for new surgeon but in the mean time, I checked BCBS revision requirements and it must have changed since I looked into it 2 months ago. Now it says:

"The individual must have serially documented active participation in a non-surgical weight reduction regimen for at least 6 continuous months, in the 2 years prior to surgery, to enable both behavioral changes and adequate assessment of anticipated postoperative dietary maintenance. These efforts must be fully appraised and documented by the physician requesting authorization for surgery"

What exactly does this mean? I have records from like MyFitnessPal, MapMyRun, a Couch-2-5k app, my surgeon's records of weights and fills from 2010-2012... but I haven't seen a PCP regularly for several years. Would any of these personal records count? Or am I going to have to do a 6 month PCP diet?

I'd like to go into the appointment with documentation if I have it available. Thanks for any info you guys have!

What my patient advocate told me was 6 months supervise dietitian with adequate weight loss and a doctor supervising that dietitian and adequate weight loss. They have forms that need to be signed every month from the pcp and the dietitian.

[goregalore 16]

Thanks for your input! Fortunately I didn't have to do any of that.