Does anyone know how the long approval process of bcbs il with a ppo is? Is there extra criteria?

Does anyone know how the long approval process of bcbs il with a ppo is? Is there extra criteria?

That's what I have. Here is the deal...

1 meeting with surgeon

1 " " Nutritionist

1 psych evaluation

BMI of 40 or higher or of 35 and 1 co morbidity

Chart notes of you weight, from your dr for 2 years

I have BCBS PPO. Here's a link to the current medical policy: http://medicalpolicy.hcsc.net/medicalpolicy/home?ctype=POLICY&cat=Surgery&path=/templatedata/medpolicies/POLICY/data/SURGERY/SUR716.003_2012-02-01#hlink

And here's the criteria, direct from the medical policy:

PATIENT SELECTION CRITERIA FOR COVERAGE

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:

1. Diagnosis of morbid obesity, defined as a:

• 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
    

2. 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 post-operative 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.
  
  

Hope that helps!

Oops! Sorry!! I don't have ppo.

Oops! Sorry!! I don't have ppo.

I'm so glad you said this because I was getting myself all worried about this 2 yrs of medical records business!! haha, I had H.M.O last year and found out they required an 18 MONTH supervised diet, so I switched at the beginning of the year when open enrollment came around. The PPO doesn't require any diet, but you had me scared that you knew something I didn't know!

Diva1 - In rereading, I'm not sure I answered your question... if you're wondering about approval time-wise, from start to finish, you're looking at a few months - depending on how quickly you can get the psych eval, the NUT visit and surgeon consult scheduled, plus you'll need to see your PCP for a physical. Then once you see the surgeon, they will likely order more pre-op testing which could be lengthy, depending on your medical history.

Once you get all that done, tho, BCBS will give a response within 30 days - usually much less - and then you can schedule your surgery.

Patience is a virtue I really don't have, so the best advice I can offer is to stay on top of all your providers, call frequently for cancellations if they tell you it's gonna take a while to get an appointment, etc. You can definitely hurry this along by being involved and following up with everything.

Diva, where are you located? Do you know where you want to have your surgery? There are only certain providers that BCBS will approve to do bariatric surgery - if you need help with that, let me know!

The chart notes are nothing more than your weights from any time you visited the dr in the last 2 years. No biggie. I actually didn't have them because we just moved from IN to WA and my old dr never did send them.

Journey girl and makemyownluck, thanks so much. I'm in Illinois and I'm working with Dr.Kane at Kane Center through Alexian Brothers Hospital, it's a blue cross distinction center for bariatric surgery. They said that as of Feb 1 bcbc il is waiving the 6 month management plan. I have had my initial surgeon appt, psych and nut last week. I had an ultrasound today, physical with pcp next week and pulmonary appt in April. They submitted my file to bcbs yesterday.

Good luck to you, Diva1!! Alexian is a great hospital, I'm sure they will take great care of you.

I'm hoping for a speedy (and favorable) reply from BCBS - for you and me both!!

Good luck to you both!!

I was approved! One week!

I have BCBS IL and I started my process on March 7th. My insurance policy only began with BCBS IL on Feb 1. I met with the surgeon and nutritionist, had my psych eval, did the endoscopy procedure, and they submitted to insurance this past Friday. I was approved TODAY, just one business day later, and my surgery is scheduled for April 29th! After waiting for years to have insurance that covered the procedure and hearing about so many insurance denials and setbacks I am amazed that it went this smoothly!

I have BCBS IL and I started my process on March 7th. My insurance policy only began with BCBS IL on Feb 1. I met with the surgeon and nutritionist' date=' had my psych eval, did the endoscopy procedure, and they submitted to insurance this past Friday. I was approved TODAY, just one business day later, and my surgery is scheduled for April 29th! After waiting for years to have insurance that covered the procedure and hearing about so many insurance denials and setbacks I am amazed that it went this smoothly![/quote']

My case was received by them on Tuesday, I'm hoping for an answer this week. Do you have PPO?

I have ppo, it was submitted last week Tuesday and the surgeon office called on the following Monday to inform it was approved. I have to get pulmonary approval before a date is set. I have that in two weeks.

My case was received by them on Tuesday, I'm hoping for an answer this week. Do you have PPO?

Yes, I have employer-paid PPO. My plan specifically states that it covers WLS with no prereqs. I only switched from my husband's insurance to my employer's because of this fact.

Also, call and bug them! They were really nice when I called and told me I'd been approved before they sent the letter to my surgeon's office.

BCBS got my surgeon's request on Tuesday. I called them yesterday to check status - it was still being reviewed. I called them today - AND IT'S APPROVED!! They said the letter would probably be sent out tomorrow because the note was just added today saying it was "medically necessary".

When I went to my final surgeon consult, I was scheduled that day. I'm going to call them tomorrow and see if there's ANY chance it could be done sooner (doubt it), but I'm definitely a GO for surgery on May 2nd.

I'm so happy I could cry!! Good luck to all of you to get a quick and POSITIVE response from them!