Anyone have Blue Shield CA? question....

[reachbree 140]

Does Blue Shield CA still require 6 month pre-op diet? Ive read in different places on here that they no longer require this. I met with my surgeon on today and the staff there are not aware of this change.

I will be calling BS on today, but just wondering what you experience is/was.

I sure do hope I don't have to wait 6 months!

[2goldengirl 2,076]

Blue Shield does NOT require six months any longer for their Health Maintenance Organization members. They changed their policy effective 7/31/15. Here is a link to their medical policy index. own to the "B's and you see bariatric surgery.

https://www.blueshieldca.com/provider/authorizations/clinical-policies/medical-procedures/policy.sp

Link to the policy itself: https://www.blueshieldca.com/provider/content_assets/documents/download/public/bscpolicy/Bariatric_Surgery.pdf

And the section concerning patient selection criteria:

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.

You need to meet BMI criteria as well, that information is earlier in the policy.

[Sharon1964 2,530]

I have Blue Shield of California, and I agree with what was posted by @@2goldengirl

I started on my path a little over a year ago, and after six months of nutrition supervision, I was approved in June 2016, several days before they announced the change. Just my luck.

[reachbree 140]

and that's exactly what I keep hearing and reading from posters etc however I just got off of the phone with BS of CA and they sent me the actual Prior Authorization request form that my Dr would have to complete and send to them and it does state that you have to have 6 consecutive months of weight, dietary and physical regimen documented.

:'(

[reachbree 140]

and the top of my form says Blue Shield of California...

I have ***, does that make a difference?

Maybe that is why.

or maybe I was sent an old form?? i'm so confused right now...

The Form the representative sent me doesn't even have an effective or Revision date on it. Those sections are blank.....

Edited January 6, 2016 by reachbree

[2goldengirl 2,076]

Sigh. People who answer 800 numbers aren't paid to think. And Bariatric Pal asterisks out "***", which is why I spelled it out in my post.

Let me say this again: Blue Shield of CA for Health Maintenance Organization members follows the policy I linked above. period, no matter WHAT anyone answering an 800# says. I don't blame you for being confused, since Blue Shield's member services staff are.

Here is how you do this.

1. You make an appointment with your PCP. Take a copy of the Blue Shield policy (not the whole 48 pages, just the first four will do).
2. Talk to your PCP about a referral to a bariatric surgeon. make sure the surgeon gets a copy of the policy (though mine didn't believe me when I sent it to them, hence my Grievance with Blue Shield). You have to get a referral to see the surgeon.
3. Make an appointment with the surgeon. Some surgeon's offices want you to see an RD and a psychologist first before they will see you. this is where you explain again that your health plan criteria don't require these before consulting with a surgeon (surgeon may want you to have them, but you can certainly see the surgeon first)
4. IF surgeon's office won't see you without these two visits despite Blue Shield's policy, call Blue Shield and file a Grievance. Blue Shield will overturn the decision not to see you first, because Blue Shield requires their delegated medical groups to follow Blue Shield's policy.
5. Work with your surgeon's office to complete any required preop testing and diagnostic work. My surgeon wants the RD and Psych visits, a sleep study (which means a referral to a pulmonologist) , an upper GI (for which I just needed an MD order from the surgeon) and an EGD (which means referral to a GI specialist from the surgeon).
6. Expect to wait for all this to be accomplished. I had to wait nearly a month just for an initial appointment with the GI doc, for example. I don't know how long it will take after I see her to get the EGD done.

I hope this helps!

Edited January 6, 2016 by 2goldengirl

[reachbree 140]

Thanks goldengirl.

Ok, I do have a copy of the policy.

I actually started this process a couple months ago and have since then gone to the Seminar, had my first Supervised diet visit ( a month ago) and started all the blood work and getting ready to schedule the U/S and Upper GI etc.

I also met with the surgeon for the first time today as well as had my psych eval and passed.

The Surgeon wants me to loose 10lbs before surgery...and gave me the diet that I am to follow from now until the liquid pre-op.

I am only stuck at this point where the Bariatric surgery center says that If I have B/S CA, then I have to do the diet for 6 months....I told him BS recently changed that and they said they have not received any paperwork stating that change so they are still going by 6 months unless I can provide them with that notice of change.

I will send them a copy of the first few pages of the policy and see what comes of it...

Thanks so much for that info!

I know i sound like a bunch of whining but 6 months is alot compared to 3...not to mention I prefer to have surgery in mid-late Spring, rather than summer....

BTW- I just printed the auth form directly from the providers site and it IS different from what the rep sent me. It does not list the 6 months!!!! matter fact it just says History of weightloss attempts etc....but does not specify how long except minimum of 3 months which is fine by me

Edited January 6, 2016 by reachbree

[swizzle 120]

Hi! Same boat here!

Do you know if this is the same for H M O as it is for P P O? Nothing I've read seems to make a distinction between the two.

Thanks!

-S

Edited January 7, 2016 by swissenback

[2goldengirl 2,076]

Hi! Same boat here!

Do you know if this is the same for H M O as it is for P P O? Nothing I've read seems to make a distinction between the two.

Thanks!

-S

The policy change is for H M O, and does not apply to P P O so far as I know.

[reachbree 140]

The Prior Auth form says you have to provide documentation of prior weightloss attempts.

How are you all doing that? Does UNsupervised attempts count?

[2goldengirl 2,076]

Yes, they count. I'd done so many over the years that I'd forgotten the names of some of them. I just made a list and gave it to both my PCP and my surgeon. I did it as a table, and I added which year, how much I'd lost, and how long the loss lasted.

And don't forget this - completing the form is your surgeon's job; properly documenting how you meet the criteria for surgery is their job as well. They will need information from you, but they've gotten many, many patients authorized for surgery - whereas the only experience you personally have is your own.

[RileyBear 1]

I am a medical review nurse for insurance companies. I did all the leg work for approval for the sleeve. My BMI is 38% however I am on HCTZ for BP and on a medications for GERD and depression. I first called the insurance company for a copy of the medical policy.I have Arkansas BCBS. The policy requirements are

• 
  
  • Patients with morbid obesity with a Body Mass Index (BMI) greater than or equal to 40; AND
    
  • Have failed a structured weight loss program; AND
    
  • Are well-motivated and understand the risks of the surgery and the restricted eating habits which follow the gastric restrictive or bypass surgery; AND
    
  • Are over the age of 20.
    
  
  

Body Mass Index of 36 – 39

Patients with Body Mass Index of 36 - 39 may be considered for coverage if they meet the other criteria above, and have high-risk co-morbid conditions (e.g., uncontrolled diabetes mellitus, uncontrolled obstructive sleep apnea as defined in the sleep apnea policy, uncontrolled hypertension, uncontrolled hyperlipidemia)

I then wrote a 4 page letter outlining my past attempts at weight loss, family history and statistics with references. I faxed it to the pre-auth team with directions to have review by the medical director....I called my PCPs office and had them fax my last 5 years of records, this occurred on a Monday. I called insurance company on Tuesday and verified the information was received. I then faxed my letter for pre-approval. I called and verified they received and stated I would be calling daily for updates. Within 2 days I was approved. SO please do your due diligence. Don't only rely on your physician but become your own advocate!

[RileyBear 1]

Oh and I forgot to add, I also had my PCP write a letter of medical necessity that was also faxed to BCBS. Make sure you get a copy of this letter.

I just read the policy. May I ask what you BMI is and o you have any comorbidities?

[2goldengirl 2,076]

@@RileyBear, in CA, Blue Shield delegates review of authorizations to delegated medical groups. Blue Shield's policy is used, but there are more than 200 medical groups in the state. It works differently here than in other states with other insurance products.

Letters of medical necessity aren't used in H M O products in CA. The medical groups contract with specific bariatric surgeons who prform surgeries at specific hospitals contracted with each of the health plans. If the surgeon's office can't get the surgery approved, the surgeon can't get paid, so they are very motivated to get surgeries approved the first time their request is submitted. A decision has to be made within five business days in CA so long as the required documentation is provided at the time of the request.

[reachbree 140]

Thanks so much for the info and push.

Im definitely ready to go forward and do whatever I need to.

Unfortunately, im having a hard time convincing my surgeons office that BS/CA no longer required the 6 month pre-op diet.

Matter fact, they are saying that it has been raised to 12 months for many.