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. “

It won't help the OP, but for others you can call your insurance and get a letter of coverage (not sure that's the right name). Basically they'll give you a letter that states exactly what's covered and what the costs under the plan would be. My DR required that in addition to their pre-approval check. In my case it saved me from a surprise because it turned out I had an extra $1,000 deductible for inpatient surgery that I didn't know about.

Mine totally took almost a year. I went to the seminar, was seen by an md at the weight loss center. Then I had an appointment with the surgeon. After that 2 egd (i needed 2 because of an indent in the top of my stomach) 6 nutritionist appointments each 4 weeks apart. Then psych, then my psych drs, then my pcp. Then I could no longer use my cpap, so I needed a new sleep study and each one of these appointments took weeks to get into. So it was 10 1/2 months of the waiting game. Good luck. I would also call and ask the insurance company. Gl


SW 350 (11/15)
BSW 260 (10/17/17)
CW 224 (1/3/18)
RGW 199
GW 175

Thanks for all the help and input. Right now I'm planning on going in on Tues for preop. Dr. office said to move forward as if everything has been approved. They requested from the dr the 12 month for pcp and from my endocrinologist. They wanted to see that I've been with them the last 12 months since I have thyroid issue. Hopefully showing in the notes my weight as well as discussion will be enough to push it through. I'll keep you posted. Not sure if they will open on Monday since its a holiday. I sure hope so

Pretty sure this is your WLS policy. Scroll down to page 6 for criteria.

https://www.bcbsnc.com/assets/services/public/pdfs/medicalpolicy/surgery_for_morbid_obesity.pdf

16 minutes ago, Losingit2018 said:

Pretty sure this is your WLS policy. Scroll down to page 6 for criteria.

https://www.bcbsnc.com/assets/services/public/pdfs/medicalpolicy/surgery_for_morbid_obesity.pdf

Yes, it is. Thank you

Hopefully the will approve now they can see that I've been to my pcp and endocrinologist within the last year. I'll keep everyone posted so that if anyone looks later they can see how it turned out.

Just an update for anyone that follows or looks for information regarding BCBSNC

1/9 - submitted to BCBSNC

1/11- notice from BCBSNC it was pending (missing visit information within 12 months from PCP and endocrinologist) Needed these items before they could send it for review

1/12 - notice from BCBSNC that it was denied - needed the following items after review - Letter from surgeon that I understand this is a lifetime change and that I'm prepared - Also needed clearance for surgery from endocrinologist since my thyroid levels were low during last labwork

1/17 - After new lab work and meeting with Endocrinologist to get letter submitted again to BCBSNC - now waiting...

Good news, lets hope this does it.

I had to do basically 9 months of preop stuff with BCBS. So it ended up being about a year after initial consultation till surgery.

I have Independence BCBS (Philadephia based area), they required a 6 month weightloss program before surgery was approved. BCBS does differ by state and areas and may require a longer or shorter period. The way the wording was laid out, it sounds like your doctor needs to provide proof that you have been consecutively making an effort to lose the weight in a 12 month period. If the doctor is able to provide the necessary documentation, it sounds like insurance would be able to approve it, however, if they are not providing enough documentation, you may need to wait until it's been a full 12 months of proof. If you are in a "program", your doctor will be able to provide that, however, if you have only seen your doctor a few times, and they were aware you were trying to loose weight, but they did not provide a program for you, they seems as if it would not be enough proof. My surgeon's office has a specific weightloss program ALL patients must do before surgery. We need to meet with a dietiation multiple times and a physiologist and a psychologist to make sure we are progressing.

Good luck to you!

Wow I'm glad I don't have BCBS, in my area it's Anthem BCBS but from all the sorrow it's giving people I am glad I have something else. Reminds me of the old joke about life insurance-you are betting you need it, the insurance carrier is betting you don't, if you win the argument you're dead and can't enjoy your victory.

Sent from my VS880PP using BariatricPal App

Soooo .....

After getting clearance from my endocrinologist and submitting to BCBSNC I got approval today

Surgery is scheduled for 1/25 - I am soooo nervous now. The whole process has gone by so fast

For anyone who comes here looking to see how my process went this is my timeframe

11/6 - met with PCP for normal visit and decided to ask about a referral for WLS

11/13 - attending WL seminar from surgery center

11/17 - met with WL surgeon

11/27 - met with NUT

11/29 - met with NUT

12/5 - met with PYSCH

12/6 - endoscopy, xray, bloodwork

12/7 - met with PSYCH

12/13 - ultrasound

1/3 - H & P with surgeon - scheduled for 1/18

1/9 - submitted to BCBS - delay because of blizzard

1/12 - BCBS requested additional info before they review

1/15 - BCBS denied - requested clearance letter from endocrinologies bc thyroid level low

1/16 - new blood work and clearance letter from endo - rescheduled for 1/25

1/18 - resubmitted to BCBS

1/19 - approval from BCBS

1/25 - surgery

not too bad of a process considering 2 snowstorms and holiday season

just over 2 months to get it all going and finished

I have BCBS here in VA, they did approve me but I also had to be in a weight loss program for about 6 months, they also had to look and see that I had a history of up and down weight loss. My surgeons office was well versed in what was going on and assisted me in filling out the paperwork (no lies, or stretching the truth just assistance in filling out the paperwork to get approved the first time). I have a record of yo-yo weight loss and thankfully it was enough to get me approved and able to move on. My advice is just go with the program and you should be fine, even if they want 12 months of you in a program just go along with it, the results you see at the end will make the journey sweeter. Not bragging just giving you facts, I have dropped over 88 pounds in less than 6 months, my quality of life and energy levels have gone through the roof! You are worth it, just work the plan and about 13-14 months from now you will be much happier!!

11 hours ago, Gotalose said:

Soooo .....

After getting clearance from my endocrinologist and submitting to BCBSNC I got approval today

Surgery is scheduled for 1/25 - I am soooo nervous now. The whole process has gone by so fast

For anyone who comes here looking to see how my process went this is my timeframe

11/6 - met with PCP for normal visit and decided to ask about a referral for WLS

11/13 - attending WL seminar from surgery center

11/17 - met with WL surgeon

11/27 - met with NUT

11/29 - met with NUT

12/5 - met with PYSCH

12/6 - endoscopy, xray, bloodwork

12/7 - met with PSYCH

12/13 - ultrasound

1/3 - H & P with surgeon - scheduled for 1/18

1/9 - submitted to BCBS - delay because of blizzard

1/12 - BCBS requested additional info before they review

1/15 - BCBS denied - requested clearance letter from endocrinologies bc thyroid level low

1/16 - new blood work and clearance letter from endo - rescheduled for 1/25

1/18 - resubmitted to BCBS

1/19 - approval from BCBS

1/25 - surgery

not too bad of a process considering 2 snowstorms and holiday season

just over 2 months to get it all going and finished

Nice! Now the hard part is done, the surgery will be easy compared to that process!

Congratulations on the approval! You will be having surgery tomorrow if everything goes right! I know that you are happy, I am 5 months out and the only thing that I wish is that I would have done it MUCH sooner! Drives me nuts because I used to work for the hospital that I did my surgery. Started working for a another hospital and went through their program and they ended up getting out of bariatrics altogether! Ended up having to go back to the other hospital ( would have gotten a 25% discount with my current employer) but oh well, thats life and at least I am 90 pounds lighter and feeling much better than I was over 6 months ago!! You will be just fine!

Good luck tomorrow, you've beat the insurance stall tactics at their own game, now get,operated, get healthy and get along with,your life. The 25th is your rebirth day.

Sent from my VS880PP using BariatricPal App