????Blue Shield of Ca - 6 monthly weigh ins no longer needed!?

[Sandra86says 92]

HELP! ????I was denied in July for gastric sleeve. I met all the requirements (psych evaluation, BMI 49, HBP, Type 2 diabetes and PCOS) except I didn't have 6 monthly weigh ins which they required at the time. My PCP was floored! He was so upset at my insurance company for requiring the 6 monthly weigh ins, my health is in really bad shape for a 29 year old! However, I've been reading that Blue Shield of Ca just changed their requirement and that they no longer require the 6 months of weigh ins! I'm on month 3 and need advice! Should I call my surgery group and have them submit to insurance?! Has anybody had experience with this!? Thanks so much!!! The sooner I get this the better!!! ????????

[queencity 62]

Yes, call the surgeons office and have them resubmit the packet for pre apporval to your insrance and since they chaned their requirements they will have to approved you. Just becasue you started before they made the change doesnt mean they wont approve. Goodluck

[2goldengirl 2,076]

Blue Shield changed their requirements effective July 31. Definitely call your surgeon's office and have them resubmit. I've attached a copy of the policy to this post. Your surgeon's office can always submit the first page of the policy along with your packet.

Blue Shield didn't share this change with their participating medical groups. It's actually your medical group who approves or denies your surgery. Blue Shield requires that all of their participating medical groups use Blue Shield policies for bariatric surgery. What the medical group is supposed to do is review the policy each time they approve or deny something. This is the biggest change I can remember in 20 years where we didn't get some kind of notice. Approving these surgeries is part of my job (I can't deny anything, an MD has to do that)

Anyone in California who is a member of an *** plan can get their health plan policy for any procedure, usually online. It's the law in CA.

I hope this helps, and good luck!

Bariatric_SurgeryBlueShieldPolicy2015.pdf

[Sandra86says 92]

Blue Shield changed their requirements effective July 31. Definitely call your surgeon's office and have them resubmit. I've attached a copy of the policy to this post. Your surgeon's office can always submit the first page of the policy along with your packet.

Blue Shield didn't share this change with their participating medical groups. It's actually your medical group who approves or denies your surgery. Blue Shield requires that all of their participating medical groups use Blue Shield policies for bariatric surgery. What the medical group is supposed to do is review the policy each time they approve or deny something. This is the biggest change I can remember in 20 years where we didn't get some kind of notice. Approving these surgeries is part of my job (I can't deny anything, an MD has to do that)

Anyone in California who is a member of an *** plan can get their health plan policy for any procedure, usually online. It's the law in CA.

I hope this helps, and good luck!

THANKS SO MUCH!!! I just called my surgeons office and left a message! Like I said the sooner I get VSG the better! I really appreciate your help! ❤️ I think it's funny how I was denied on the 22nd only for Blue Shield to change the policy on the 31st! If that was the case I should've waited a week lol

[Kellyfitz4 53]

Hi did this policy change in any other states? I gave BCBS of Michigan and was told 2 months ago that I have to complete the 6 month medical check before surgery. I'm in the process now, 4 more months to go!

[newmebithebypass 713]

no the policy only changed in california

no the policy only changed in california

[Trinn 139]

Yes. It's changed. And my surgeon's office wouldn't believe me when I told them, but they filed after I repeatedly asked, and I was approved within the 5 days that BS of CA now promises. So, I had my first NUT appointment on June 1, My initial surgical consult on Jun 29, and got my approval on August 24. I was sleeved on Sept 1. From the initial info session to surgery was 3 months, 2 days. And I only had 2 NUT visits pre-surgery. My second one was July 30, and she approved me for surgery based on my compliance and 20 lbs weight loss in two months. :-)

So, in my case, because they wouldn't believe me that it had changed, I had to be pretty insistent. By the way, I called BS and they repeatedly offered to call my surgeon's office and explain the new coverage policy to them. I didn't take them up on it, but I did have to keep reminding them of it. For example, the insurance submitting person said, "Oh, it will take a month to get back the approval" and I was like, "No, BS's policy is to return a decision within 5 days." "Oh, but they don't really do that." "No, they assure me they will."

Edited October 29, 2015 by Trinn

[2goldengirl 2,076]

I did attach a copy of the policy to my post - so that anyone can have give to their surgeons office that as proof.

The 5-day turnaround is a requirement by CA law for *** plans for routine (non urgent) requests when all necessary information is received at the time the request is submitted. That part isn't just Blue Shield.

Edited October 30, 2015 by 2goldengirl

[shaeluv 16]

I am currently employed and my employer excludes bariatric surgery on their insurance policies. I have been through appeals for the last year and am finally just ready to go out and purchase a healthcare plan outside of my employer and pay the extreme out of pocket cost for the premium to have this medically necessary surgery... My question is there ia the bronze, silver and gold etc Blue shield plans but all say they "cover" bariatric- How much did you guys actually pay out of pocket for the surgery, hospital stay etc? I am just trying to plan ahead- if I have to pay the premium and a deductible I want to be prepared.

I am currently employed and my employer excludes bariatric surgery on their insurance policies. I have been through appeals for the last year and am finally just ready to go out and purchase a healthcare plan outside of my employer and pay the extreme out of pocket cost for the premium to have this medically necessary surgery... My question is there ia the bronze, silver and gold etc Blue shield plans but all say they "cover" bariatric- How much did you guys actually pay out of pocket for the surgery, hospital stay etc? I am just trying to plan ahead- if I have to pay the premium and a deductible I want to be prepared.

My question is with the bronze, silver and gold etc Blue shield plans all say they "cover" bariatric- How much did you guys actually pay out of pocket for the surgery, hospital stay etc? I am just trying to plan ahead- if I have to pay the premium and a deductible I want to be prepared.

[swizzle 120]

Hi 2goldengirl, thank you so much for this information! The medical group I'm starting with also said there would be a 6 month weigh in period prior to authorization. This will be great to be able to bring in and help facilitate the ball to roll a little faster!

I'm having trouble finding the exact section regarding the change in the document you included. All I've been able to dig out of it is a portion that states on 7/31/15 there was a "policy clarification update"... but I am totally lost on a lot of the more administrative side! Can you help me find in the document where specifically it talks about the change?

Again, thank you SO much! I was dancing across the room when I found this thread!!

-S

Edited January 7, 2016 by swissenback

[Deletemyacct 39]

This was an awesome thread to read, thank you everyone for sharing. I have bcbs-ca but am located in FL. My employer just switch to them this plan yr. I called & was told the procedure needed to be medically necessary, I though that was odd considering what I've been reading but this post made a lot of sense. I originally went to an oband center who currently have me on the 6mth plan but,I will be attending a seminar w/ uhealth on Tuesday & hope to go from there

Sent from my LGMS631 using the BariatricPal App

[2goldengirl 2,076]

@@Deuel30, the elimination of the waiting period is only for CA H M O plans, it doesn't hold true for other plans in other states.

[Deletemyacct 39]

@@2goldengirl oh ok, thank you for letting me know.

Sent from my LGMS631 using the BariatricPal App

[Trinn 139]

I didn't have an HMO plan; the changes I detailed were for the PPO Also, I was talking about Blue Shield of CA, not Blue Cross/ Blue Shield. Those are TWO DIFFERENT COMPANIES. So, changes in BSCA don't affect BCBS-CA.

Don't confuse the two companies -- they're not related.

[Trinn 139]

I didn't have an HMO plan; the changes I detailed were for the PPO Also, I was talking about Blue Shield of CA, not Blue Cross/ Blue Shield. Those are TWO DIFFERENT COMPANIES. So, changes in BSCA don't affect BCBS-CA.

Don't confuse the two companies -- they're not related.