PA- Highmark PPO Blue (Blue Cross/Blue Shield)

[Band_Groupie 3]

Just thought I'd post so this info. can get passed on to someone who might need it. I'm not an insurance person, but this is what I had confirmed today by the insurance expert at my surgeons office. Highmark PPO Blue requirements:

- Must submit these:

1. Letter of Medical Necessity from PCP or referring physician

2. Six months of Consecutive Medically supervised diet/exercise visits and logs within past 2 years (from surgery date).

-Must be 6 mo. in a row, so 7 visits total incl. start

-Logs must show progress of both diet and exercise (Weight, calories, min. of exercise, etc.)

-Logs must show education/discussion is taking place

-Can do this with your PCP or Dietician

3. Psychological evaluation-states that patient has a clear understanding of procedure & can adjust to lifestyle changes. Need complete letter. Cannot be any longer than 6 mo. Before surgery date.

4. Nutrition evaluation with a registered dietitian- for meal planning/health choices in the future. Need complete letter. Cannot be any longer than 6 mo. Before surgery date.

- Must have either of these to be classified as Morbidly Obese (and be older than 18):

1. BMI of at least 40

2. BMI of 35-40 with comorbidities- Although this word is plural in the policy they tell me you only need 1 of the big ones, and as many minor as you can document

-Need at least one of the big "life threatening" comorbidities, which are:

-Obesity related major Cardiovascular problems (medication or

documentation)

-Diabetes (medication)

-Hypertension/High Blood Pressure (medication)

-High Cholesterol (medication)

-sleep Apnea (CPAP)

-Not sure, but I think Obesity related cancers also count with documentation

-Need as many minor comorbidities as you can document (ie. Asthma,

Degenerative Joint Disease, Stress Incontinence, etc.)

Edited November 14, 2008 by Band_Groupie