Horizon Blue Cross Blue Shield of New Jersey

[kathywb 0]

My paperwork was sent in and in 5 days I was rejected by bcbsnj - they said i only went to five weight loss meetings when my drs notes and letter clearly says six.

I'm hearing they are now going to ask for a consult with medical weight loss dr/nutritionist plus six visits. Something is changing. I've emailed my surgeon to please appeal for me. Did everything else timely - even have medical release done, etc. Anybody hear anything about this? Thanks.

[livngoodandfree 0]

Hi you guys,

This is my first post. What a great resource you guys are! I hear everyone speak of the six month physician supervised diet. I want to begin but am having a hard time getting the specifics about this criteria. Is it a specific program or programs or is it any program my primary physician puts me on and monitors. BMI is 38 and diabetic. Thanks for any help. Thx-Tara

[daco525 0]

I just went for my first of six appts this week. I believe it is just a supervised weight loss program with your doctor. He needs to document in his notes what you are doing as far as diet and exercise. I sure can't see going back to weight watchers. I have done this so many times. All I want to do is complete my six months and submit everything and hopefully receive approval.

[Raf 0]

I wanted to know if you had to go through a 6 mouth Diet program for them to approve you???? I am having such a hard time with BCBSNJ right now. They want something with in the last 12 months that I have done something like that.... Well the last 12 months I have been looking for the right surgeon and going through everything else to get this done.... I have sent them stuff from the last 8 years and now they want the last 12 months.... I am ssssooooo upset I just want to get this done so bad..

[daco525 0]

Prepare to jump through alot of hoops. Here is what I am told BCBSNJ needs for approval. Documented weights from the past two years (these need to be from your doctor). A six month consecutive weight loss program monitored by your doctor. If you miss even one month you have to start all over. You need a BMI 40 or great or 35-40 but then you must have co-morbidities. All of this must be documented by your doctor. You can send other info to support your claim but without this I think they will deny. I started the process of looking into a surgeon in Nov. I am now jumping through all the hoops and I am hoping to submit everything and get an approval in May. Best of luck. Let us know how everything turns out.

[Raf 0]

I actually been through a whole diet program with my dr. for the past few years. They now want something from the last 12 months.... Well the last 12 months I have been working on getting the lap band surgery. I have seen different surgeons and finally picked the right one for me and went through all of the other stuff, like sleep test, cart dr. and x-rays and more. I am just so upset. I guess I'll write them a letter myself and see what happens. I just don't get the insurance co. they want me to do what I have done for the last few years for 6 months and they have all of that from my Dr. but they still want something else...

I know someone that got this done that has the same insurance & same dr. She only did the sleep test & had x-rays done. She actually gained the weight to have the lap band done. I don't understand how she did it...

BCBS of NJ Sucks!!!!

Thank you for your response.. I will let you know how I make out.

[daco525 0]

If your BMI is 40 or above then I believe you can just go for your tests, have your weight verified by your doctor and you are set. The problem is if your between 35-40 then they ask for the 6 consecutive month doctor supervised diet. I actually had 9 months of weight watcher where I went consecutively every week and this is still not good enough. I just started my 6 months appt. last month. I will be finished in May. Also they want the actual doctor notes from each visit and the notes must contain info about diet and exercise.

[Raf 0]

My BMI is 44.4......

I am writting an appeal letter right now and getting another letter from my family dr. stating I have done all of this that they ask over the last 8 years...

[daco525 0]

I think you should definitely appeal. I am surprised that they are giving you a hard time with your BMI above 40. My understanding is you are exempt from the 6 month weigh in and I thought you just needed to have a doctors note and have all the pre-surgery test completed. Did you try call the ins. to find out why they are denying it? My BMI is 38 so I have to jump through the hoops to prove medical necessity. I have several co-morbidities (diabetes, hypertension, high cholesterol) but I still have alot of hoops to jump through.

[Raf 0]

I am going to try to call today - when I get a chance here @ work. Well good luck to you I hope you get approved and thank you.. I'll keep you posted.

[Lori Ann 0]

I had BCBS of NJ and the approved my surgery the first time. I had diabetes and high blood pressure. My BMI was 41. I had to have all the sleep tests, psych test, x-rays, meet with a nutritionist and have a referral that my primary doctor approved....They lost my paperwork and everything had to be resubmitted....but I tell you...I called BCBSNJ (Horizon) every day until I got the approval. At one point, I was missing something that I had my doctor fax over. I really believe the best thing is not to sit back at wait....you call the insurance company and that way you know exactly what stage your claim is in....ask for answers and ask questions. Good Luck!

[daco525 0]

Be sure you document the time, day and person you spoke with. The last time I called and reviewed exactly what was needed for approval and they even gave me a reference # after the call. Keep at it, I think it will all turn out in your favor.

[kathywb 0]

1/7/09

I had emailed before my surgery re denial by BCBS - maybe

some of these facts will help someone.

I appealed BCBS decision and got ok in 5 days because, even after doing everything right, the nurse at BCBS who picked up the fax with all my records FOR APPROVAL via my surgeons office said my 6 visits were only 5 and thats what she said to her director at BCBS (there are many). This is happening at BCBS in Newark, NJ. I dont know if they do the whole country or just NJ. I think my particular surgeons

office is now requiring 7 months because of this which makes no sense. Something needs fixing.

I called and spoke to a nurse in Appeals who agreed with me - I re-sent my primary's letter detailing the six month weight loss (and 5 year annual weights, copies of 6 month notes, and his recommendations and concerns). She passed it on thru with her ok to her Director.

I started my six month weight loss plan before I settled on a surgeon. Yes it has to be within the last 12 months. You may be able to use WW records within the last 12 months but you have to check. I'd rather do once a month in dr's office for six months. My BMI was 46 I had high bp, high cholesterol - no apnea, diabetes.

I may be wrong about this - but I think if you go to a surgeon as a lapband OUTpatient the rules via BCBS might

be eased. I was obviously an inpatient.

Good luck and thanks to everyone for their help.

KB

[daco525 0]

Now I am concerned that they may not see my 6 months weigh in as a full 6 months. Here are the dates of my dr. appts. 12/26, 1/22, 2/16, 3/9, 4/12, 5/1. I planned on having the dr send his notes from each visit indicating weigh in, diet and exercise. I hope they don't say the first appt 12/26 was an initial weigh in and then we need 6 months after of actual diet. Anyone have any experience with this. I don't want to get hung up another month, I am really trying to get the surgery done in the summer since I don't work then, more time for recovery.

[tamtam1965 0]

Hey, everybody, this is my first post. Southern Ocean County Hospital has a new "hub" for bariatric surgery. I had my first visit with the surgeon last week, and my first of six nutrition appts late in Feb. My BMI is 46, and I have the following co-morbid conditions: severe sleep apnea, diabetes, GERD, HTN, & asthma. Does anybody have experiece with the State plan, NJ Direct 15, which is a BC/BS program. I'm relying on SOCH for all my instructions, but I don't want to make any mistakes. I have been very overweight for at least 10 years (with weights documented in my chart), but have never paid for an "official" weight loss program before. Also, what if my internist doesn't agree that this is the right road for me (they seem very eager to get the business at SOCH, and disagree completey)?

thank you.