Anthem BCBS (in Missouri) - Insurance requirements

[KatallacStrong 49]

Hey y’all! This is my first post as I’m still in the consult stages of trying to get the VSG surgery. I meet with the surgeon for the first time on 7/3/18 however I have a few concerns with the requirements of my insurance; Anthem Blue Cross Blue Shield.

A friend (and coworker) of mine had this procedure done in December 2017 so I have a bit of info on how things will go with our insurance, but I have concern with what is considered as this “continuous 6-month non-surgical weight-loss regimen” requirement. I have called BCBS several times all of which I have been told the same thing; the 6 months have to be consecutive/continuous in the past 2 years. This means no breaks in visits and there are no exceptions; they must be month to month.

I understand there are requirements to be met but I’ve been having an internal battle with whether or not to have the surgery for the better part of the last 3 years. I have lost nearly 80 pounds on my own through diet and exercise but since I quit smoking in late 2016 I have regained nearly half of that weight back regardless my efforts; or at least that’s how it feels. That sure was a long way around my question, lol sorry y’all!

My question is, has anyone been approved for their surgery with BCBS (in Missouri) without having the consecutive/continuous appointments? In early 2017 when I realized I was gaining I started seeing my primary doctor every other month to try and get ahold of things; he felt one months time just wasn’t enough to see if what we were doing was working or not so he wanted every other month. This has been unsuccessful but I feel like with all my visits to him and the documented attempts at the various methods I’ve tried should suffice.

Now, I have found out that these “6 months” can be with my doctor and not necessarily a nutritionist; that’s not my concern. My concern is I have documented appointments in January 2017, May 2017, July 2017, November 2017, January 2018, March 2018, May 2018 and today I have one to mark June 2018; I made today’s appointment since apparently there’s no way I can get approved without my appointments being consecutive. In the beginning of 2017 it wasn’t every other month until we saw I was still gaining; we had chatted via email several times between appointments.

It’s not that I want to rush into this surgery that has me so concerned. What concerns me is that I’ve tried so many different attempts with both my primary physician and a dietician (March 2018) and nothing; my doc said when people have a lot of weight to lose it is common for there to be struggles like this. What else is there for
Me to try aside from shots and such; I definitely don’t want that.

Another issue I have is if I do have to do these appointments consecutively that means my sixth apt will be October 2018. I work in legal (contracting) and I cannot take off more than 1-2 days at a time through January; it’s our busiest time of year. What that means is it will have to wait until early next year which is a new year of deductibles; ugh my brain hurts.

I know my surgery center can help but any thoughts or insight to this are greatly appreciated.

Thanks y’all, sorry for the ramble<3

[Snapple 42]

I have Anthem BC/BS in MO and they would not cover any bariatric procedures under my policy.

[KatallacStrong 49]

On 06/21/2018 at 13:14, Snapple said:

I have Anthem BC/BS in MO and they would not cover any bariatric procedures under my policy.

Wow that’s crazy! When I called the various times I was told it was covered. Did they tell you why you weren’t covered? I wonder if your company opted out of it? That’s super interesting.

The friend of mine who is a coworker said it covered hers. I wanted to get a gauge of OOP cost so I called and that’s when they told me it was covered at 80% in-network OR 90% at a”Center of Excellence” (COE). I had no idea what that was so I googled it and it’s specific facilities that hold a standard that Anthem approves. The surgeon I am going to see is at a COE so my surgery will be covered at 90%

[Snapple 42]

I have an individual plan since we are independent contractors and this was the only plan I could buy. It's BS. And all thanks to Obamacare. I have really, REALLY crappy coverage and my prescription drugs aren't even covered until I hit my deductible $6000 deductible.

Good luck to you and I wish you the best!

[KatallacStrong 49]

On 06/21/2018 at 13:26, Snapple said:

I have an individual plan since we are independent contractors and this was the only plan I could buy. It's BS. And all thanks to Obamacare. I have really, REALLY crappy coverage and my prescription drugs aren't even covered until I hit my deductible $6000 deductible.

Good luck to you and I wish you the best!

Oh wow that’s crazy! I’m sorry to hear of the awful coverage but I appreciate the insight from someone else in Missouri.

Thanks Snapple!

[ash_allen 1]

I have Anthem BCBS in NC and yes I have to do the 6 month consecutive weigh ins. Yes I felt like gosh this will take forever, but I’m almost at my 3rd weigh in. Plus you will have a host of preop testing that will take up a portion of that time.

[KatallacStrong 49]

On 06/21/2018 at 17:45, ash_allen said:

I have Anthem BCBS in NC and yes I have to do the 6 month consecutive weigh ins. Yes I felt like gosh this will take forever, but I’m almost at my 3rd weigh in. Plus you will have a host of preop testing that will take up a portion of that time.

Thanks ash_allen. I know these weigh-ins have to be consecutive, I was just wondering if anyone has met with their doc similarly to I have and have been approved. I read somewhere where a patient got a recommendation letter and was approved based on the regimen they had with their doc even though it wasn’t consecutive.