Bcbs Il ppo what has been your process?


8 posts in this topic

Hi everyone!! I am excited I did my seminar today and received all my paperwork to fill out and send back to centegra WLC, they will run my insurance and see what is covered and costs will be. Does anyone have this plan and trying to get GB? I'm hoping to have my stuff done and ready to have surgery before the new year just in case insurance gets ripped apart again... which I hope it doesn't because I love the plan I have. And is anyone going thru the centegra system? I am hoping to get in with Dr. Heydari but they did say he has a 2 month waiting list to be seen... but in the mean time does that mean I can see the nutrionalist and do the psych eval?

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I have bcbs personal choice. I think each employer covers different things but I went on the ibx web site and it gave me an estimate of the cost. I did not have to do the 6 month prep so it was only 2 months from my first appt to surgery. They were also very fast with approval--2 days, I think.

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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:

  1. 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
  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 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

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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:
  1. 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
  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 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



Thank you! I actually just got the call for my first consult with Dr. Heydari for next week! And I have to schedule my bariatric/ nutrionalist screening. It's really happening! Im so excited and scared.


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Same here! I'm hoping for a late October/early November surgery date :) This will be my early xmas gift to myself this year.

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I have BCBS Wellmark Iowa with reciprocity in Minnesota (Mayo). I still have to do the 6 months supervised diet with a physician [emoji853] I just hope they don't spring some other requirements on me at the last minute!


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15 minutes ago, insul817 said:

I have BCBS Wellmark Iowa with reciprocity in Minnesota (Mayo). I still have to do the 6 months supervised diet with a physician I just hope they don't spring some other requirements on me at the last minute!

Bummer! Too bad BCBS doesn't have their medical policies match from state to state :(

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Same here! I'm hoping for a late October/early November surgery date [emoji4] This will be my early xmas gift to myself this year.


I'm hoping for surgery by December, it seems that the program I'm going through is booked like weeks out and if there is one day available I have to take it! I'm excited and nervous. This will be a big change in lifestyle... (mostly food).


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