Insurance approval question

[Lizzz78 3]

Hi! I have a consultation in 2 weeks with a bariatric sugeron . Im curious about insurance approvals. Does anyone out there have federal BCBS? What are the requirements? What was the approval process? Im at a BMI of 35.6 and have no comorbities. There is no way I could pay cash for this surgery, so Im just wondering if there is anyone else out there who doubted that insurance would approve the surgery? I just really don't want to get my hopes up. Thanks for any input!

[Newme17 3,444]

I can't speak for BCBS, but most insurances require you to have a bmi of 40 or more with or with co morbidities. A lower bmi, in your case, is usually accepted only if you have a co-morbidity or two. Thus, many opt to go to Mexico if you don't meet the requirements. But I'm sure someone who has BCBS could and will definitely weigh in here for a clearer answer.

Edited March 6, 2017 by Newme17

[Grandeur40 0]

I have BCBS of Illinois and this is the response I got from an inquiry I made. All plans are different within BCBS as far as what they pay but I tend to think the "guidelines" to qualify are consistent. Don't quote me on that though

Surgical treatment of morbid obesity may be considered eligible for coverage when all of the physical, clinical and psychological indications are documented according to Blue Cross Blue Shield of Illinois current medical policy. A letter of support and/or explanation is helpful but alone will not be considered sufficient documentation to make a medical necessity determination.

We are not in a position to consider the request for surgical treatment of morbid obesity due to the lack of available medical documentation to determine medical necessity based on Blue Cross Blue Shield of Illinois medical policy. The following documented clinical information is necessary for further review.

For a member to be considered eligible for benefit coverage of bariatric surgery to treat morbid obesity, the member must meet the following two criteria:

1. Diagnosis of morbid obesity, defined as a:
- Body mass index (BMI) equal to or greater than 40 kg/meter (* see guidelines below for BMI calculation); OR
- BMI equal to or greater than 35kg/meters with at least one (1) of the following comorbid conditions related to obesity that have not responded to maximum medical management and that are generally expected to be reversed or improved by bariatric treatment:

o Hypertension, OR
o Dyslipidemia, OR
o Diabetes mellitus, OR
o Coronary heart disease, OR
o sleep apnea, OR
o Osteoarthritis; AND

2. Documentation from the requesting surgical program that:
- Growth is completed (generally, growth is considered completed by 18 years of age); AND
- Documentation from the surgeon attesting that the patient has been educated in and understands the post-operative regimen, which should include ALL of the following components:

1. Nutrition program, which may include a very low calorie diet or a recognized commercial diet-based weight loss program; AND
2. Behavior modification or behavioral health interventions; AND
3. Counseling and instruction on exercise and increased physical activity; AND
4. Ongoing support for lifestyle changes to make and maintain appropriate choices that will reduce health risk factors and improve overall health; AND
- Patient has completed an evaluation by a licensed professional counselor, psychologist or psychiatrist within the 12 months preceding the request for surgery. This evaluation should document:
1. The absence of significant psychopathology that would hinder the ability of an individual to understand the procedure and comply with medical/surgical recommendations, AND
2. The absence of any psychological comorbidity that could contribute to weight mismanagement or a diagnosed eating disorder, AND
3. The patient's willingness to comply with preoperative and postoperative treatment plans.

The member and their physician(s) are urged to review the full text of the Blue Cross Blue Shield Illinois BCBSIL/ medical policy on this subject on the BCBSIL Website at www.bcbsil.com. Choose the "provider" link at the top of the Website and select Medical Policy under the Standards and Requirements tab. You may need to click I Agree to the terms page to be directed to the Medical Policy. Once on the Medical Policy page you will need to click on Active and Pending Medical Policies. You can use the search box and search for Surgery for Morbid Obesity or Bariatric Surgery.

If you have any further questions or concerns, please contact our customer service department at the toll-free number on the back of your Blue Cross Blue Shield identification card or via the Message Center on Blue Access