BCBS of GA. 6 Months Med. Supv. Weight loss?

[MegHealthy 11]

Good Morning everyone! I am 5'5" and 243lbs. That puts me right at a 40.4 BMI. From what I understand my BCBS of GA requires that I participate in a non-surgical weight reduction regimen for at least 6 continuous months. During that time BCBS requires of the 6 month program as follows:

The clinical record includes:

• A description of “what” the individual actually did in the program, that is, did they follow the diet and exercise recommendations as an active participant for six continuous months in the two years prior to surgery?

• A record of the individual’s weight at the time of each preop visit, and the amount of weight loss achieved each month of the documented 6 month period

• A description of the actions taken by the surgeon and nutrition team, prior to surgery, to encourage the individual’s compliance and address any individual obstacles to positive behavioral changes

Ok. Have any of you experienced that in this 6 months weight loss program that your BMI dropped below the requirement of 40 resulting in denial of coverage for the procedure? At this time, because I don't know if PCOS and untreated borderline high cholesterol counts as co-morbidities, I want to see if the drop below 40 will derail my efforts. Thanks you all for any help in advance!!!!

[Liz The New Me 281]

I have BC/BS in NC. My guidelines pretty much say the same thing. But I had documented history with my doctor's going back years, that they filled out and say's yes to the V. Sleeve. I also have 5 months with a nutritionist the year before. When the W L center filled out all the forms and also entered the Physiatrist evaluation it went thru with no problems. But if you have to do six months W. Loss don't loss to much and take that chance of not having it done.

[MegHealthy 11]

That's what i'm concerned about-taking the chance and being denied because I lose some on the med. supv. diet. The fact that BCBS wants the weight reported for every pre op visit makes me think that if I do lose and get under that 40 BMI that they could deny. I could possibly lose - and would like to try before WLS but I don't want to ruin my chances at getting sleeved. I don't have a medically supervised weight loss before this that would qualify for what BCBS wants- several months on adipex a handful of the other medications, low carb, low calorie, but I have a hard time adhering for too long and well... none of those are six months consecutive. I would really like this tool to help me succeed. I wish I knew more people who have BCBS of GA or locally who have had this procedure but with so much stigma seems like no one talks about it. I, for one, am excited to get some help and hope.

[Briswife15 889]

I have Anthem BCBS in Connecticut and have the same requirements. I'm not positive, but think they use your starting weight, and it is ok if you go below a BMI of 40 during your 6 months. Can you ask your surgeon's office? They deal with this all the time. I have the opposite problem. I gained 9 pounds in month 4!! Ive lost it again in month 5, but not sure if I'll get denied for the weight gain!!

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[MegHealthy 11]

I hope you won't get denied! I'll ask my Surgeon's office to but i'm always worried they will miss something or I will and that will cause denial. Thanks though! If I do find anything definitive out i'll be sure to post and hopefully help someone else!

[LetaMae 11]

I have BCBS and live in GA. I had my first Dr. visit in January 2018 and had sleeve surgery August 2018. My doctor gave me a checklist of things to do that was required by insurance and it would pretty much qualify you for the procedure. I weighed 247 w/ 40 BMI and also had high cholesterol and sleep apnea which were both documented. If you loose weight between visits, I don’t think they will deny you just because of that. That’s a good thing. I lost in between visits and it was never an issue. I was with Kaiser before switching and tried so hard to loose weight and everything I did and all the meds I took were documented and accepted by BCBS because it was within the last 12 months. I switched to BCBS just for the surgery because Kaiser wouldn’t cover it.

SW 245
CW 208
GW 160

[MegHealthy 11]

CW 208? That's A-MAZING! I will double check with my surgeon - i'm not sure if what my med records say confirms any comorbidity or not, if so, maybe I can get to a 35 and still be covered.. Maybe it's like you experienced and any weight loss would be a good thing and encouraged. I may be able to (who knows) because I can lose sometimes, I just regain, I always regain.. that's why i'm thinking this tool will be exactly what I need to help and motivate me along the way. Congratulations on your success! How are you doing after your procedure? I'll post here if I do get a specific answer from my doctor.

[CyndieRI 251]

Briswife15 - I have BCBS in Rhode Island and I too gained in the middle of my pre-op diet. I ended up losing it by the end - but it had no effect on my approval. I hope the same is true for you! Good luck!

[Briswife15 889]

CyndieRI, thanks so much for that. I'm encouraged that your weight gain in the middle didn't affect your approval! Fingers crossed.

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[Jenwill630 119]

I am about to switch to Highmark BCBS DE in order to have my surgery.

Last night, my Dr. told me that Highmark changed their medical policy and there is no longer a 6 month supervised diet period.

So I went onto the Highmark website, scrolled down toward the bottom to Medical Policy, then hit search for Obesity. Sure enough the policy changed on 9-17-18.

What I am saying is double check to see if your policy has changed at all part way through the year.

[MegHealthy 11]

That's a great suggestion! I will make sure I set a reminder to check it, I know it's still my requirement right now so you never know! I think it's valuable to meet with a nutritional specialist and all but six months seems excessive.

[LetaMae 11]

Meg, yes 208! 207 as of today. I am doing soo good. I had my surgery done at Piedmont Hospital in Atlanta and stayed for one night. No one can prepare you for the first few days after surgery though. It was pure hell for me but I stuck to my plan and pulled through. I’m 11 weeks out and down 38 pounds. I can say that I do not deny myself of anything at this point but bread and sodas. Regardless of what I eat, I am full after 3 bites but I have taught myself to eat throughout the day which has been my biggest struggle. I take my Vitamins, drink Water and exercise when I can. I will post a pic of before and now. I have my next appointment with my nutritionist in next month and I see my surgeon again in March.

[LetaMae 11]

This is my latest before and after.

[MegHealthy 11]

You look ah-mazing!!!! Congratulations on your success! Love that before and after! Can’t wait to get an ‘after’ to!!!

[Frustr8 7,886]

Leta Mae, you went from Hi ya to Come here,Mister! I'm what you have been searching for! Girl you do look so Fine!