Horizon Blue Cross Blue Shield of New Jersey

[daco525 0]

I have to do a 6 month documented weight loss program with my family doctor. When I first brought up the lap band to my doc he seemed opposed and gave negative feedback. I went out on my own, did my own research, located my own surgeon, spoke with people who have had it done and went to a meeting where they discussed the procedure. I went back to my family doctor, gave him all the info I learned and proceed to present my case as why this would be a health benefit for me. He agreed and said "I will do anything you need for me to help you". I thanked him and told him this is what I came here for, his support. If I did not get his support, I think I would have looked for another doctor to do my 6 month visits with. I have been with my present doctor for over 5 years so I did not want to do this but I wanted someone on my side. I don't know anything about your plan but I would start with calling them, make sure there is is no weight loss exclusion, ask them exactly what they need for approval and document the date and name of who you spoke with. You meet the standards for NIH so you should not have a problem as long as you give the ins what they want. At least this is what I have been told. Good Luck.

[Melissa Anne 0]

Hi Everyone!!

I got my approval from Horizon BCBS of NJ this week!! I was shocked that it only took 2 weeks! My date is 2/18 - Im nervous, excited, happy, anxious - everything all in one!! I also got engaged this week - so it's been a whirlwind for me!! Anyone else in February?

[daco525 0]

How exciting, February is your month. Maybe you should plan a valentine's wedding next year....just a thought...I am celebrating my 18th wedding anniversary this valentine's day. Best of luck to you...you have alot to Celebrate. i bet you will be looking gorgeous in your wedding dress.

[Melissa Anne 0]

How exciting, February is your month. Maybe you should plan a valentine's wedding next year....just a thought...I am celebrating my 18th wedding anniversary this valentine's day. Best of luck to you...you have alot to Celebrate. i bet you will be looking gorgeous in your wedding dress.

Thank you so much for your kindess :w00t: It's great to have friends on this site.

[BLKsAunt 0]

I am quite concerned...this is written in the Horizon BCBS medical policy and haven't seen anyone mention this and what exactly does it mean? Does it mean the WW book?

Documentation of successful completion of at least 6 consecutive months of supervised conservative weight loss program, diet programs/plans (e.g., Weight Watchers, Jenny Craig), or the Horizon Obesity Disease Management Program.

Successful completion means formal documentation or photocopies/print-outs of progress notes of at least monthly follow-up by the supervising physician, other health care provider, or program coordinator including the patient’s weight and progress relative to the goals set at the start of the program.

(NOTE: Pre-printed check-off forms and summary letters are NOT acceptable documentation for this requirement.)

[ldgayle27 0]

BCBS of NJ is very difficult. I have been trying with them for over 2 yrs with 2 denials, however, at present I am appealing. My BMI when I applied was 39.9 but they denied me anyway. I then reapplied and my BMI was 40 but b/c my BMI for 1 of the 6 month dieting monitoring program dropped below 40 they denied me; eventhough I have thyroid disease, shortness of breath and amenorrhea, etc. i appealed and am presently waiting for a decision because now I have hypertension and have become a bit depressed, plus recent blood tests my doctor did shows I am post menopausal at 27, among a lot of other findings. They are very hard to get approved with but I am keeping my fingers crossed. Goodluck, maybe you will be much luckier than I was.

[BLKsAunt 0]

BOY oh BOY, that is not what I wanted to hear. They were very, very rude to the Bariatric RN who called them on Friday. I hope that doesn't set the tone. Do you know if the employer is self-insured or not (residual). My employer is self insured. They still have to follow NIH guidelines. I heard the BMI was based on your wt at the beginning of the diet. Do you have their medical policy or their Requirements for Morbid Obesity

This is what two CSR told me. And they were very very nice.

1. BMI of 35 or greater

2. M/O for 5 yrs or greater

3. Behavioral therapist support

4. Pro-Op eval w/ notes from the surgeon

5. Six months of documented medical history and life improvements such as diet and exercise

a. Six months of supervised diet and nutritional counseling

6. Two letters of recommendation from MDs, other than the surgeon

7. Original photos of body mass (pic of myself)

8. How the Sx will affect my lifestyle

9. How the excessive weight is affecting it now

So all of these items were covered by the surgeon and my FMD, in the letter of medical necessity, where applicable.

1. Description of procedure

2. Dx codes

3. Prognosis and length of Tx

4. Procedure Code

5. Brief Medical History

Would you pls PM me w/ your email addy.

The moment I get a denial, I'm contacting Obesity Law and Advocacy Center

I'm to onery to be jacked around this stage in my life. The law is the law.

[bgaylz 0]

Hello,

do anyone have a example of the 6 month notes required by bcbs of nj my doctor just don't seem to get it...help

[BLKsAunt 0]

I do. I headed out and won't be back until late. PM me your email address. BTW, they approved my Sx the very date my insurance lapsed. Dirty rats! I went to MX for my Sx.

[bgaylz 0]

Thanks Again.