May Not Be Able to Get My Surgery Due to No PCP with Anthem BCBS

[ThreeOhThree 76]

I am really upset. Trying to hold back tears. I do not have a PCP, I am not required to have one to see a specialist and no one ever informed me that I would be required to submit records from one. It is not even mentioned in the requirements I had BCBS email to me awhile ago, just the 6 months of continuous care in a 2 year period.

"The individual must have serially documented active participation in a non-surgical weight reduction regimen for at least 6 continuous months, in the 2 years prior to surgery, to enable both behavioral changes and adequate assessment of anticipated postoperative dietary maintenance. These efforts must be fully appraised and documented by the physician requesting authorization for surgery".

I called my surgeon today to check and make sure they received my Thyroid test as it was the last thing on my checklist. I was informed that it was received but they still have not received 2 years of weight related medical records that is required by BCBS. I have been seeing this doctor for the required 7 months ( 1 consultation and 6 months of appointments). Before him I saw another Dr. in his practice ( who has since left the practice) in 2017 for 5 months but I ultimately chickened out. Now they are asking for records from a PCP before they even submit to BCBS. I dont have a PCP. Before seeing the WL doctor in 2017 I had a baby in 2015 and its literally the only time I have seen a doctor in the past few years. They knew this in 2017. They were informed again when I started up in 2018.

I feel like an idiot. I've paid thousands of dollars at this point going to an from the doctors, getting tests and procedures done...just to be stagnant. My surgeon is supposed to remove my gallbladder at the time of surgery as well because gallstones were found in one of those tests. I am tempted to just go get my gallbladder removed and call it a day. I wonder if I can just go see a random PCP and be all like "Hey I need WLS can you sign this?" I doubt it I am calling them again tomorrow to explore options , I am not too hopeful. Has anyone else ever had this issue? Or I am I the only one who avoids doctors unless I'm having a baby or wls

[notmyname 591]

I have the same requirement. That requirement is 6 consecutive months sometime in the last two years. If you've done that with your surgeon, then you don't need records from a PCP. I'd call their insurance coordinator again. You will likely eventually need to see some kind of GP to get your medical clearance for surgery, but you definitely do not have to have had a PCP for the 2 years leading up to surgery.

[Briswife15 889]

I have Anthem BCBS and agree with notmyname. I just had gastric bypass 8 weeks ago, and Anthem approved without any input from my PCP. I filled out lots of paperwork for my surgeon which included my own list of how many times I tried to lose weight on my own, and failed. Presumably my surgeon submitted tht info to Anthem. But again, i did Not need anything from PCP. Good luck, and don't give up! I'm rooting for you!

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[ARMoma45 353]

8 hours ago, ThreeOhThree said:

I am really upset. Trying to hold back tears. I do not have a PCP, I am not required to have one to see a specialist and no one ever informed me that I would be required to submit records from one. It is not even mentioned in the requirements I had BCBS email to me awhile ago, just the 6 months of continuous care in a 2 year period.

"The individual must have serially documented active participation in a non-surgical weight reduction regimen for at least 6 continuous months, in the 2 years prior to surgery, to enable both behavioral changes and adequate assessment of anticipated postoperative dietary maintenance. These efforts must be fully appraised and documented by the physician requesting authorization for surgery".

I called my surgeon today to check and make sure they received my Thyroid test as it was the last thing on my checklist. I was informed that it was received but they still have not received 2 years of weight related medical records that is required by BCBS. I have been seeing this doctor for the required 7 months ( 1 consultation and 6 months of appointments). Before him I saw another Dr. in his practice ( who has since left the practice) in 2017 for 5 months but I ultimately chickened out. Now they are asking for records from a PCP before they even submit to BCBS. I dont have a PCP. Before seeing the WL doctor in 2017 I had a baby in 2015 and its literally the only time I have seen a doctor in the past few years. They knew this in 2017. They were informed again when I started up in 2018.

I feel like an idiot. I've paid thousands of dollars at this point going to an from the doctors, getting tests and procedures done...just to be stagnant. My surgeon is supposed to remove my gallbladder at the time of surgery as well because gallstones were found in one of those tests. I am tempted to just go get my gallbladder removed and call it a day. I wonder if I can just go see a random PCP and be all like "Hey I need WLS can you sign this?" I doubt it I am calling them again tomorrow to explore options , I am not too hopeful. Has anyone else ever had this issue? Or I am I the only one who avoids doctors unless I'm having a baby or wls

I also have BCBS and my policy specifically stated that I receive my 6 months of weight loss visits from a physician OTHER than my surgeon.

[ypease 177]

Not sure if this would work for you. On one of my appointments, I gave a detailed list of what, how long and how many times I utilized some program and/or diet. I made sure he entered it as we spoke. I also then asked for a referral to a Nutritionist. Now, I don't need referrals either. BUT! now they have a written submission for assistance in regards to weight loss efforts. I have attended my Nutritionist appt religiously and she has submitted reports to my Dr for every session. Requirements are more than filled.

My insurance doesn't cover wls. So, I am self pay. However, I have fulfiller there requirements, should the policy change before October. That is when I am scheduled for my wls.

[Dabeyhive 206]

i have anthem bcbs . Hey , Before i started this process i didnt have a PCP. I went to anthem website found a PCP threw them called and scheduled. I told my dr what im doing and he agreed surgery is whats best. With in 2 days my NEW pcp sent my medial necessity form to my bariatric center . Let me know if you have questions i just had my surgery 5/6/2019

[debra102364 148]

I think you could go get a PCP. I have on been with mine for a few months and told her my past history. She had already took blood work and in seen me and seen my health conditions. In which she wrote all the diets I have done and that she suggests according to her findings that I have the Gastric Sleeve. If you I would at least try.

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[ThreeOhThree 76]

Hey ya'll I just wanted to update. Checked again with my insurance I do not need PCP and the attending physician performing the surgery has to be the one to submit everything which is great. I have a group policy through Anthem BCBS of Wisconsin.

Since I have posted here I talked to the doctor's office about 4 times. This week I have called twice just to make sure there is not anything else that I needed to do or submit. My file is still "in queue" waiting to be sent or "paperwork being gathered" to be sent.

My issue with seeking out a random PCP is the thought that they would have me do even more blood work and labs just to tell me I am pre-diabetic, blood pressure and cholesterol levels are normal (thank goodness)...et cetra. My surgeon requires everyone to see a gastroentologist like 2 months in. I have had ultrasounds and scans, an upper endoscopy, and other blood work.

You all have been a lot of help I work in insurance but it is still so mind blowing how different policies/providers require different things before submitting.