confused about the approval process

[losinglily 17]

Hey, everyone. I just got the referral to see a surgeon approved. Is it possible to get a pre approval from my insurance (BSBC CAL)? I am so afraid that I will have jumped through these hoops only to have the surgery denied. Thoughts or advise? Thanks!

[jane13 2,256]

@@losinglily - you will probably have to meet some requirements. I have BCBS Fed employee and 3 required classes, meeting with NUT and head doctor. It was after all of that was completed before the paperwork was submitted for approval to BCBS. That took about 10 days for the results to be back to me.

[Sharon1964 2,530]

Pre-authorization for surgery without a surgeon giving your medical information is not going to happen for the majority of insurance.

Your surgeon needs to evaluate you to see if you are a good candidate for surgery, and then he will send in a pre-auth request form with your medical information.

In the meantime, you can call your insurance company and get a copy of their bariatric policy in writing, so you will know exactly what the requirements are.

[Nylaj 45]

Call BCBS & find out their requirements. You should have done that first. Know your benefits, what will you have to pay, & what they expect out of you.

I have BCBS North Carolina & they don't require anything if you have BMI over 39.

I just submitted it (I do authorizations for a living) & gave BCBS my height, weight, & BMI.

I got an approval in 3 days.

Each BCBS has different requirements.

I am assuming CAL is California? BCBS California is BCBS Anthem.

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ANTHEM BCBS – REQUIREMENTS FOR WEIGHT LOSS SURGERY

In Am I Covered by OC StaffOctober 19, 2013

Anthem BCBS does cover weight loss surgery as long as your policy does not specifically exclude coverage. ObesityCoverage strongly feels that morbid obesity is a disease and every insurance company should cover these life saving procedures. So we are happy to report that Anthem BCBS covers weight loss surgery. In fact, most of the Blue cross Blue Shield network has some sort of coverage for weight loss surgery.

It is important to know that your employer can typically opt-out of weight loss surgery insurance coverage for their employees policies. Opting-out typically saves the company money on their premiums. Contact information for your Anthem BCBS is listed below. Even if your policy excludes weight loss surgery, because BCBS has shown that these types of surgeries are medically necessary you might be able to appeal their exclusion. Before calling make sure you see our questions to ask before calling your insurance company section.

Note

Blue Cross of California is the trade name for Anthem BCBS so your criteria for weight loss surgery will be the same as it is here.

ANTHEM BCBS PRE-APPROVAL REQUIREMENTS

The items below are the minimum necessary for approval of your weight loss surgery.

• Body Mass Index (BMI) of 40 or greater OR…
• a BMI of 35 or greater with at least 2 comorbidities.
• Primary Care Physician’s Letter.
• Active Participation and Documentation of non-surgical methods of weight loss.
• 18 years of age (special consideration if under 18 with severe morbid obesity and special circumstances).
• Consult and recommendation from a weight loss surgeon.
• Psychological evaluation
• Nutritional evaluation

Policies Included in Coverage

• Blue cross Kentucky
• Blue cross Virginia
• Blue cross Wisconsin
• Blue cross Ohio
• Blue cross California
• Blue cross Georgia
• Blue cross Missouri
• Blue cross New York Empire

TYPES OF WEIGHT LOSS SURGERIES COVERED BY ANTHEM BCBS

Recently gastric sleeves have begun to be covered by some of the large insurance companies as a primary weight loss surgery. Currently, gastric sleeves are considered experimental procedures and are not covered.

Covered Weight Loss Surgery Procedures

• Laparoscopic Gastric Bypass
• Open Gastric Bypass Surgery
• Gastric Banding – including the Lap Band and Realize Band
• Duodenal Switch also known as Biliopancreatic Diversion
• Gastric Sleeves

Unsure which surgery is right for you? Take our bariatric surgery test!

Lap Band Fills Covered?

Anthem BCBS considers Lap Band fills a medical necessity when required to meet the proper level of weight loss. This is true only if you’ve had a previous adjustable gastric banding procedure that met all of the criteria laid out for that procedure. Typically, if you paid cash for the procedure ongoing lap band fills will not be covered by insurance.

Procedures Excluded From Coverage

• Mini-gastric bypass
• Banded vertical gastroplasty
• Any other ‘experimental’ weight loss procedure

Is a Second Weight Loss Surgery Covered if Gastric Banding Didn’t Work?

Surgical procedures following a previous weight loss surgery that did not result adequate weight loss, such as a lap band or realize band to a gastric bypass, gastric sleeve or duodenal switch are covered by insurance when the following criteria are met:

• The patient continues to meet all the medical necessity criteria for bariatric surgery, and
• There must be documentation that the patient was compliant with the original post-operative dietary and exercise program, and
• 2 years after the original weight loss surgery, weight loss is still less than 50% of pre-operative excess body weight and weight remains at least 30% of the patients ideal body weight, per BMI.

Revisions

• Revisions are covered if there is documentation of a failure secondary to a surgical complication. Complications can include but are not limited to fistula, obstruction or disruption of a suture/staple line.

Does Anthem BCBS Require Center Of Excellence?

• Yes, weight loss surgery must be done at a Center of Excellence.

Do I have to use an in-network weight loss surgeon?

• No. However, your deductible and out of pocket costs may be significantly lower if you do. And you will still need to find a surgeon that has privileges to perform the surgery at a accredited Center Of Excellence for Bariatric Surgery.

ANTHEM BCBS CONTACT INFORMATION

Anthems can be contacted at 1-866-293-2892. You can also locate a contact number and email address on their website after choosing your state.

ANTHEM BCBS WEIGHT LOSS SURGERY FULL COVERAGE STATEMENT

Anthem’s full policy on weight loss surgery insurance coverage from their web site.

[Sharon1964 2,530]

It could be Anthem Blue Cross of California (a for-profit company owned by Wellpoint) or it could be Blue Shield of California (a non-profit owned by California Physicians Service). They are separate companies in this state. The only plan I've ever seen that says Blue Cross/Blue Shield of California is the federal employees plan, and I think they do that because pretty much every other state does it. Federal employees are processed through Blue Shield of California.

[tamirn 90]

How can i get a print out like this for Kaiser???

[tamirn 90]

How can i get a print out like this for Kaiser???

[MissAKY 32]

How can i get a print out like this for Kaiser???

Call Kaiser and they should be able to provide it to you via email.

[MissAKY 32]

Hey, everyone. I just got the referral to see a surgeon approved. Is it possible to get a pre approval from my insurance (BSBC CAL)? I am so afraid that I will have jumped through these hoops only to have the surgery denied. Thoughts or advise? Thanks!

Hey - congrats on taking on this new journey. I have BCBS of CA (Anthem). I had to complete the following requirements

- 6 months supervised weight loss program - I told my dr about the past 10 years of serious dieting

- 1 visit with a psychiatrist

- 2 visits with a nutritionist

- Barrium test (to see the shape of my throat and stomach)

- EKG

- Blood work

- Chest X-Ray

- Attend 2 surgery orientation classes (required by my dr office)

Tu 5/26

I had my initial visit with my surgeon to get the ball rolling to start surgery process.

W 5/27

First appt with nutritionist

Completed all labs and tests required. Took a total of 90 minutes for blood work, barrium test and chest x-ray - including wait time.

W 7/15

Second appt with nutritionist

M 7/20

Psych eval

T 9/1

Final visit with nutritionist

F 9/4

All documents were submitted to surgery scheduler to submit to insurance

Th 9/10

Submitted to insurance

F 9/18

Insurance approved surgery and booked surgery for 10/12/15

In preparation for surgery I have the following requirements

- Pre-op clearance from PCP

- Attend orientation with El Camino hospital intake nurse

- Attend nutrition class that goes over food, Vitamin, etc post surgery

- Pre-op with Dr. Khalil (surgeon)

- 2 week all liquid diet before surgery

[tamirn 90]

Okay so i went and seen my pcp she had me do a bunch of lab work.. she sent over my referral got a call about 3 days later and now im scheduled for the a 4 hour orientation where i meet the surgery team!! So excited all this happend in one week!!

[hsbower 1]

I have anthem health keepers plus and I see my surgeon for the first time tomorrow. I'm so confused about the process and if there is or isn't a waiting period. I'm getting conflicting reports from the insurance people. HELP!

[Trinn 139]

By the way, in June this year Blue Shield of CA did away with the 6 month requirement, and everything else --they no longer have any sort of checklist. Instead, they basically say, "Hey, doctors, tell us the patient is a good candidate." I got approved 2 months after I started seeing a NUT and surgeon with BSCA.

[halalo 13]

Trin is it really like that now? Even if bmi is 39 and no co- morbidity? I didn't read this in their website.

[Trinn 139]

Let me get you a link: https://www.blueshieldca.com/provider/content_assets/documents/download/public/bscpolicy/Bariatric_Surgery.pdf

Yes, you still need comorbidities with a BMI below 40, but the list is no longer limited -- if your doctor says it's a comorbidity, it is. OTOH, they used to have a large check list of things that one needed for approval, including six months of nutrition visits, etc. That has been replaced with this paragraph:

"Patients should have documented failure to respond to conservative measures for weight reduction prior to consideration of bariatric surgery, and these attempts should be reviewed by the practitioner prior to seeking approval for the surgical procedure (e.g., Weight Watchers, Jenny Craig, Optifast, MediFast). The timing, intensity and duration of the preoperative timeframe should be individualized and left to the discretion of the patient and provider. However, given the elective and life changing nature of these procedures, and the necessity of proper education and instruction in the lifestyle changes inherent in both the immediate and long term postoperative management, it is recommended that three months elapse between the initial bariatric consultation and the date of surgery."

Edited October 9, 2015 by Trinn

[halalo 13]

Thanks trin I'm waiting for my sleep apnea study to submit my case to my insurance

Edited October 9, 2015 by halalo