Blue Cross of PA - awaiting approval from Predetermination Dept

[Justin Edwards 1]

I was wondering if anyone had Blue Cross of PA PPO which from my understanding is a subsidiary of BCBS. I've been working with Kim Bariatrics in Frisco, TX for assistance with qualifying for the gastric sleeve. Initially when I spoke with my coordinator, she advised me that my insurance does cover gastric sleeve as long as I meet the guidelines set by insurance. I'm 42.1 BMI i think and that alone was enough for potential coverage. She confided to me that my plan doesn't require a 6 month diet plan, but they do want to see previous attempts of weight loss. In the past I've used phentermine and weight loss programs through several primary care physicians since 2010. I've also done diet and exercise with testosterone treatment at a Men's Health Clinic from October 2014 through February of 2015. My heaviest recently that i can remember was 328 lbs when i relocated from Chicago to Dallas this past August of 2015. In December 2015 I joined a supervised weight loss plan with a new PCP and started at 323 lbs at my first weigh in. I've brought myself down to 307 lbs again being on phentermine, supervised weight loss plan and exercise. Also I did all the required testing (stress test, sleep apnea, blood screenings, psychiatric evaluation, and whatnot through Kim Bariatrics. I was able to meet with the surgeon on 03/16/16 and my coordinator confirmed that my review packet was recieved by BCBS by 03/21/16. She stated initially that the review can take 15 business days for approval or denial, however today she confirmed that my case with BCBS is with the predetermination (??) department and that this department can take up to 30 business days to review my claim. Has anyone gotten this far and heard of predetermination? I haven't seen any threads regarding going through this particular department. My coordinator stated that I had over several pages of documentation and chart-notes from the doctors since 2010. I'm hoping I get approved and get the ball rolling. I've become very anxious waiting for the approval that I can hardly sleep.

[kmorri 1,689]

@@Justin Edwards

Hi! "predetermination" is just the name of the department that looks over the medical documentation so they can make a "determination prior" to your surgery. I don't think she meant to make you think it was sent somewhere else or different....just that it's where it needs to be and it's being processed...... If it's been submitted for more than 2 weeks you can always call the number on your card and tell them you would like to check the status of your authorization for surgery....30 days is just so you don't get too worried if it takes a long time....but at 2 weeks there's nothing wrong with calling the insurance to check..........I retired from BCBS of Florida and I'm pretty sure most all the Blue plans work very similar. Good luck!!!

[rebelchelz 52]

Dr office has submitted everything insurance for approval. Now waiting to see. 35BMI w/ sleep Apnea. BCBSOK requires at least 1 comorbidity so hopefully will be approved. Nervous because my sleep apnea is mild but I do have a CPAP. Anyone else get approved with this as the comorbidity