Blue Cross Blue Shield MA PPO Requirements

[Sue Magoo 71]

Hello:

I'm considering gastric bypass. My insurance is changing effective 12/1/16 to Blue Cross Blue Shield Massachusetts PPO. I know that bariatric surgery is covered, but I cannot tell what the requirements will be. Anybody know?

Thanks for your help. I'd like to know now, but if nobody knows, I can find out for sure once I get my insurance card.

Thanks.

Sue

[Sue Magoo 71]

By the way, all of my info on my profile is wrong. I'm a former bandster. Had it removed in 2013 and have gained back 80% of the weight that I lost with the band. I cannot get sleeved because I have gastroparesis. Would love to get back to the weight on my profile

[Raymia 565]

I'm in New Jersey I have Nj Direct Horizon PPO my friend has the same and she had no problems. No referral needed.

Sent from my SAMSUNG-SM-G928A using the BariatricPal App

[magnificent2015 34]

I recently got coverage by BCBSMA PPO, When they forwarded me the information it basically said they would only perform the surgery out of medical necessity with the criteria being:

Patient Selection Criteria

Adults over the age of 18 or who have documented complete bone growth are eligible for obesity surgery if ALL of the following criteria are met:

 The physician has indicated that the patient:

o Is a well informed and motivated patient with acceptable operative risks, AND

o Has a strong desire for substantial weight loss, AND

o Has failed other non-surgical approaches to long-term weight loss, AND

o Is enrolled in a program which provides pre-op and post-op multidisciplinary evaluation and care including: behavioral health, nutrition, and medical management AND

 The patient is morbidly obese with a BMI > 40kg/m².

OR

 The patient has a BMI >35kg/m² and the physician has indicated that the patient has one or more of the following high risk co-morbid conditions:

o sleep apnea

o Pickwickian syndrome

o Pseudotumor cerebri

o Obesity related cardiomyopathy

o Type II Diabetes

o At least Stage 1 Hypertension based on JNC-VII (SBP >140 and/or DBP >90) after combination pharmacotherapy

o Coronary artery disease, or

o Obesity related pulmonary hypertension.

Literally just copied and pasted it for you.

My surgeon coordinator said that they also require 6 months of nutritionist visits also, not sure how valid that is.

I'm currently waiting to hear whether I've been approved or denied. My BMI is like 52 but I don't have any comorbidities.

Edited November 9, 2016 by magnificent2015

[Sue Magoo 71]

Thank you Magnificent.

[magnificent2015 34]

Thank you Magnificent.

You're Welcome! Good Luck!