Urgent.. Help with BCBS

[Gotalose 24]

So I’ve done everything I was supposed to do with surgeon and they submitted to bcbsnc and now insurance is saying I need 12 month consecutive with weight loss. Why?!?!?! Would the surgeons office review all my paperwork at initial appointment have me do everything only to not have what I needed. I’ve paid for anesthetist endoscopy psych nut ultrasounds only not to use any of it if I have to wait 12 months. My pcp sent letter how I’ve been under his card for the last year and have not been able to lose weight and that it’s s medical necessity The language from insurance is obscure. Can anyone help with this. The last sentence is what gets me

“In advance of a commercially insured member receiving a bariatric surgical procedure, BCBSNC will first need to review the member’s medical records, including documentation of 12 consecutive months of active engagement in weight related treatment, as described above. Judgement regarding the scope, depth, and adequacy of pre-surgical treatment during the 12 months prior to surgery is at the discretion of the multidisciplinary weight loss surgery team, and BCBSNC does not specify the content of the treatment. “

[orionburn 1,023]

I wonder if BCBS varies between states. My insurance (I'm in Indiana) did require a 6 month monitored program, but not a year. That seems extreme.

[Gotalose 24]

If my Dr writes my letter of medical necessity stating for the last year you would think that would qualify for “judgement”

[orionburn 1,023]

To be honest I'm surprised your doctor's office wouldn't know this in advance. I can understand that they may not with some more obscure insurance plans, but I would think they would be well aware of requirements from BCBS. When I had my first consultation my nurse knew all the ins & outs of what would be required. From the start I was told it would be a minimum of 6 months. Definitely talk with your doc to see what you can do. Hopefully there's an easy way to get it sorted.

[Down South Aussie 65]

This is Interesting, i am with BCBS of CA (Live in SC) and i called BC to ask if first the procedure would be covered and was told it is the same as any other required surgery. I then spoke to the Bariatric center and they pulled up my details and it said i needed 3 months of a diet program, so she told me i would be looking at about 4 months until the surgery. Could it be the specific program you are on? i know BCBS has several different insurance programs so each one may have different requirements, but 12 months does seem kind of extreme.

[Apple203 1,314]

An entire year sounds like total overkill on behalf of the insurance company. I keep wondering, as sleeves become more commonplace, if insurance companies are gonna try to pull the brakes with tactics like really long waits, excessive preparation, etc.

I'd like to add one piece of advice that was our first "homework" assignment at the intro seminar: contact your insurance company and get a copy of your bariatric policy.

Edited January 11, 2018 by Apple203

[Sosewsue61 3,185]

Log into your insurance portal and email them (written record) specific questions. What type of documentation is required to prove 12 months medically supervised weight loss program, how much if any weight loss is required, what happens if I gain a pound one month but have a net loss ovetall, do I need to submit an exercise log, do I need a nutritionist to submit a food log, etc.

Get very specific. They have to answer written questions in writing. Then have your physician appeal the ruling.

[NikkiDoc 312]

BCBS varies on requirements. Each BCBS is essentially a franchise. Many employer plans are also not fully insured but self insured and BCBS only acts as an Administrative Services Only (ASO) provider. In the case of ASO the employer can decide if they want to cover WLS and some of the terms to get it approved.

I was covered through Horizon BCBS out of NJ through my husbands employer. It is a self funded plan not insurance. I had a 6 month monitored diet and I HAD to meet with the doctor/NP or dietician in my PCP practice at least once a month or I would start over. I did not have to show any weight loss I just needed to have documentation of a medically monitored diet. I did lose weight during that 6 months.

That sucks that they did not tell your surgeon's office about the 12 months requirement. It does sound like a soft requirement that can be waived at their discretion where mine was a hard requirement that I HAS to do.

[abefroman329 704]

"12 consecutive months of active engagement in weight related treatment"

That's not 12 months of weight loss, that's 12 months of attempted weight loss. They really want to make sure you can't lose the weight on your own before they'll pay for your surgery.

FWIW, I have BCBS of IL and only had to complete 2 months of supervised medical weight loss, and that was the surgeon's requirement, not BCBS'.

[dianedi 1]

I live in NY and The only record I needed was the 6 months I went to the surgeons office. My medical dr signed and said i've been trying to loose weight. Did you try any other weight loss programs? I worked for Jenny Craig for 11 years and I had to copy clients records for the surgery. I would call them myself and speak to them, Are they going to reimburse you for all the tests you did and paid for which if you wait a year you will have to do again. Good Luck

[MissSimpson 81]

2 hours ago, orionburn said:

I wonder if BCBS varies between states. My insurance (I'm in Indiana) did require a 6 month monitored program, but not a year. That seems extreme.

My BCBS in Mississippi also required 6 months. I missed a visit and had to start over. After all that, it had been over a year since my psych eval, and I had to do a follow up with the psychiatrist.

[LittleLizzieLilliput 919]

I landed my ass in ICU, my insurance company basically asked me to have the surgery. lol!

[Down South Aussie 65]

1 hour ago, LittleLizzieLilliput said:

I landed my ass in ICU, my insurance company basically asked me to have the surgery. lol!

See it is situations like yours that realistically shines a light that when it all comes down to it insurance companies can bypass any restrictions that they impose on the process.

Im in a position where i have several comorbities that i believe need to be factored in, as do many others. For me at one point in my past i had blood sugar levels over 1100 (my Dr didnt know how i was still walking at that point) that was a few years back but following that i asked the first time about WLS and was denied (was 365lbs at the time). So i have to wonder why the insurance companies now dont prioritize some of these applications (not saying i need to jump to the front of the line or anything crazy like that, im doing my due diligence and staying the course) as some people really need the surgery as soon as possible..

[Losebig 508]

Definitely varies by state, I had BCBS MA and they didn't have any requirements. I'd call them and ask specifically what documentation is acceptable. For example a letter from your PCP stating that you've been working to lose weight for the last 12 months without success may be sufficient. Once you know what they're looking for you can either provide it or try to appeal and see if their 'team' will accept giving a pass based on your PCP and Surgeons medical opinions. I've had ok luck appealing stuff with them in the past, but you need a PCP who is willing to push for you.

[GassyGurl 428]

Is it possible when you started the process, it was 6 months, now it changed to 12 months for the new year? It stinks whatever the reason.

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