I've got BCBS of IL, PPO through work. I also did the cost estimate on the BCBS website, and it basically said I only had to pay my max out of pocket for the procedure. I then checked my policy and confirmed that gastric bypass is covered. When I reached out to my insurance, these are the requirements they gave me in order for them to review my submission for approval. You'll notice that BCBS IL did away with the 6mo required diet back in Feb. 2012 (I pulled the current BCBS of IL medical policy on bariatric surgery and it notes when changes were made at the end of the policy). I've attached the policy PDF with the predetermination information at the beginning.
"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:
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:
Hypertension, OR
Dyslipidemia, OR
Diabetes mellitus, OR
Coronary heart disease, OR
Sleep apnea, OR
Osteoarthritis; AND
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 postoperative regimen, which should include ALL of the following components:
Nutrition program, which may include a very low calorie diet or a recognized commercial diet-based weight loss program; AND
Behavior modification or behavioral health interventions; AND
Counseling and instruction on exercise and increased physical activity; AND
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:
The absence of significant psychopathology that would hinder the ability of an individual to understand the procedure and comply with medical/surgical recommendations, AND
The absence of any psychological comorbidity that could contribute to weight mismanagement or a diagnosed eating disorder, AND
The patient's willingness to comply with preoperative and postoperative treatment plans."
I'm sure your surgeon has an entire program already put together to meet pretty much all of these requirements. My surgeon is Dr. Jonathan Wallace at Suburban Surgical out in Hoffman Estates, and their practice is a pretty well-oiled machine at this point. I just had my initial consult with Dr. Wallace on 8/9, and I've already had my insurance confirmed by them and multiple appointments set up (first set of labs, psych eval, and two required nutrition classes).
Hope this helps! I'm just starting my journey but I've done a TON of research already, if you can't tell
Current BCBS IL medical policy on bariatric surgery as of 3.15.17.pdf