Anthem BC/BS

mamato3 · October 5, 2007

I went to a seminar last night and they said that Anthem requires 2 comorbidities no matter what the BMI. According to my member services manual AND the lady I spoke to at Anthem, with a BMI of greater then 40 then no comorbidities are required. Does anybody have any idea which is correct? I have some other minor things wrong (plantar faschitis, stress incontinence, aching joints,already had to have my gall bladder removed and had gestational diabetes with 2 recent pregnancies which puts me at a MUCH higher risk of develping type 2 diabetes if I dont get this weight off). I am now SO worried that I am not going to qualify. My current BMI is 44. What do you think?

suecasb · October 6, 2007

I have Anthem BC/BS of Massachusetts and they say if your BMI is 40 or above you don't need any co-morbids..if BMI is between 35 and 40 you need at least 1 co-morbid.

dustout · October 9, 2007

I have anthem. Here is the link to their official policy:

http://www.anthem.com/medicalpolicies/noapplication/f4/s10/t2/pw_034084.pdf

35-39 BMI requires 2 comorbidities.

40+ BMI does _NOT_ require any comorbidities.

I was approved a month ago one comorbidity (hypertension) although it's being easily treated with dieretic.

Good luck and check out that policy!

mamato3 · October 9, 2007

I set up my consultation with the surgeon for Oct 16. I am pretty sure it should be covered no problem. Thanks, dustout for the website! I'm hoping to jump through the hoops and have surgery in January :eek:

Ellisa · October 9, 2007

Is the Anthem link for all states? I couldn't tell from the link if it was state specific.

Thanks for posting it regardless, it is extremely informative.

dustout · October 10, 2007

That link is not state specific. It is the general Anthem policy.

However, Anthem might provide plans which exclude bariatric surgery or states might override that policy. I don't know.

If you call Anthem they will be able to check your plan and tell you if it a covered procedure under your plan if you meet the requirements. They told me very quickly that yes it's covered. You may need to call it the official name on the policy (restrictive gastric banding I think).

Although Anthem was kind of slow, they approved me quite easily. I went ahead and went to a PPC (primary care physician aka normal doctor I've been going to) and got them to refer me so it's a tad more official looking to the insurance why you started wanting to do it.

Good luck with your insurance! Just meet those goals on the policy and you should be good!

Ellisa · October 10, 2007

Thanks for the information. I had actually called my insurance company before starting the process and was told (it seemed somewhat grudgingly) that it was covered. IF if was "medically necessary." But not what specifically was required to be medically necessary. They weren't particularly easy to talk to. The surgeon's office seemed to think I met the qualifications on my BMI. But I keep hearing that sometimes they want X number of years of medical records or X number of months on a physician supervised diet plan. So it was really nice to see the policy. It would have been so nice if they would have simply referred me to that.