I have a BMI of 35 with high blood pressure. Wondering if I will be approved. Also my insurance is a PPO, what does that mean and what kind of a difference does it make? Wondering how long the process took for others with this insurance and what other requirements they want.

call your insurance company they will be glad to talk to you about it.

I have BCBS of IL AND I work for them. First off, you ALWAYS ALWAYS ALWAYS want to check and be sure YOUR policy covers this surgery. Just because BCBS of IL might cover it, your specific policy COULD have an exclusion for it. Your FIRST step would be to call the # on your ID card and speak with a Customer Advocate in the office that handles your specific group and policy to see what YOUR SPECIFIC group/employer covers when it comes to bariatric surgery. Some groups cover it, some exclude it, and some have certain guidelines/regulations. Again, anything in THIS particular post in GENERAL information and in no way specific to what YOUR own policy might or might not cover.

Go to this link:

http://medicalpolicy...Test=true#hlink

Once you agree to the terms and service and go to the next page, you will get a search box on the left. Put in the word "bariatric" in the search box and hit the "go" button. There should be a search result for "Bariatric Surgery." Click on that and you will get the medical policy criteria for bariatric surgery. Scroll down to the "coverage" section. This is the area that is used to determine if you meet the medical criteria for the surgery.

For BMI there are 2, either a BMI or 40 or higher OR 35 with 2 co-morbidites. You can actually print this out (there is a printer friendly option at the top) and take it with you to the dr to discuss with them the criteria that has to be met. Now as far as what PPO means, that means you have to use your PPO/In Network providers in order to get your highest benefit levels. Also, if you use Out of Network, NON PPO doctors and hospitals, they do not have to write off what is over the allowed amount (agreed upon contracted rate) and they can bill you that difference, meaning you would end up with a much higher bill. You can use the provider finder on the BCBS website or call customer service or the provider finder phone # on the back of your ID card to verify if the provider is in network/PPO for you. The predetermination process CAN take up to 30 days. The Medical Review Unit has 30 days from the time they receive medical records from your doctor to make a decision. It doesn't always take that long, but that is the given time frame.

• Body mass index (BMI) equal to or greater than 40 kg/meter² (* see guidelines below for BMI calculation); OR
  
• BMI equal to or greater than 35kg/meters² with at least two (2) 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
    

I also have BCBS of IL and had no issues getting approved but I met there criteria for BMI over 40 and had high blood pressure. Take Loris info and go from there!

I have BCBS IL I am waiting to here. I do have bariatric on my plan. My BMI is just at 40.5 so let keep our finger crossed.

I have BCBS of IL as well. Used true results Dallas. My coverage was BMI >40 or >35 with 2 comorbidities. Im over 35 but without comorbidities.... but I had "hernia repair via Lap Band" coverage, so after an EGD to show hiatal hernia (practically everyone with excess belly fat has at least a small one) I was good to go. Did have to pay a couple grand out of pocket though.