Okay, so I've called BC/BS of Western New York a few times this week trying to find out specifically what I needed to do to make sure I start the process correctly so they can't deny me down the road when it's surgery time.

The first girl I spoke with told me "oh, you don't have to do anything special, just find the doctor you want to use and then there's some paperwork you have to do". I thought to myself "yea right"

So I call again, the second girl tells me that they can't tell me what the requirements are or if my policy covers it. I tell her that according to the policy, it's covered if it's medical necessary. She says "oh, well I don't know how you prove that." Very helpful.

Finally, I call the health advocate line where I speak to a VERY nice girl. She tells me my doctor has to call this special number to get the requirments for whatever has to be done to show it's medically necessary... Do they really think doctors have all this extra time on their hands to do this????? oh, and by the way, the surgeon I've picked out accepts BC/BS, but not the specific policy I have.. so now I have to find a new surgeon. Joy of joys.

Okay, which brings me to my question. How in the WORLD do you navigate the joy of BC/BS of WNY?????

Hang in there FireDust. I hope it all works out for you. You are in my thoughts and prayers...sending you Good Luck!!!

I'm not sure about BC/BS WNY, I have federal BC/BS. Your policy should have it in writing what they require. I made my appointment with a surgeon and they submitted it for pre-approval or whatever BC calls it and I was denied. I then had to appeal which I did with letters from me as well as letters of support from every one of my doctors, GYN, GP, Gastro, Pediatrist, and the surgeon. I was approved on my second go-around.

Time from first submission to approval, about 2 months.

Good luck to you!

The surgeon I've been in contact with is sending me out a packet of stuff, so hopefully I'll be able to get everything taken care of through them and just have to worry about getting a letter of support from the PCP... we'll see!

It's so silly that they make us jump through so many hoops... but, I suppose that's how they know who is serious and who isn't!

I'm in NY also and have BCBS. I called and was directed to the website Blue Cross Blue Shield Association - Leading the Future of Healthcare I was told to enter my zip code, this will take you to another website, then click on "for providers", then click on "medical policies", click on "accept", medical policies should pop up, scroll down to "surgical management of obesity...." and click on that. It should tell you exactly what is required. Good luck!

This is word for word what my policy requirements are. I would think they would be the same (I'm central NY) but I could be wrong.

POLICY STATEMENT:

I. Based upon our criteria and assessment of the peer-reviewed literature, the surgical treatment of morbid obesity by open or laparoscopic Roux-en-Y gastric bypass, and duodenal switch procedure (biliopancreatic diversion) have been medically proven to improve health outcomes and are therefore medically appropriate for selected patients. Patients must meet all of the following criteria:

A. Patients must be morbidly obese; which is defined as a BMI greater than or equal to 40 kg/m2.

B. If comorbid condition(s) exist (e.g., hypertensive cardiovascular disease, pulmonary hypoventilation, coronary heart disease, diabetes, sleep apnea, degenerative arthritis of weight-bearing joints, or metabolic syndrome) patients must have a BMI greater than or equal to 35 kg/m2. Documentation of the level of severity of the comorbid existing medical condition(s) must be submitted by the primary care physician.

C. The condition of morbid obesity must be of at least 5 years duration.

D. Documentation, from either the bariatric surgeon or primary care physician, of one or more rigorous attempts at weight reduction, totaling a minimum of six months. Documentation should include the name of each weight loss program, length of participation in the weight loss program (including any physician supervised program) and any weight loss achieved. A letter of support from the physician currently providing primary care to the member and who is familiar with his/her attempts at weight reduction, medical history and current health status (including obesity issues) is also necessary for the review process.

E. There should be no significant liver, kidney, or gastrointestinal disease present. The presence of non-alcoholic steatohepatitis or “fatty liver”, which is associated with morbidly obese patients, would not be considered significant liver disease in this instance.

F. Treatable metabolic causes for obesity (e.g., adrenal or thyroid disorders) have been addressed.

G. Patients with a history of alcohol or substance abuse will not be considered unless there is a record of at least six months of abstinence. If there has been six months of abstinence, this condition must be addressed in a psychiatric consultation.

H. Patients must be screened by their physician for major psychopathology. All patients who have current symptoms which concern the physician, or who have had a psychiatric hospitalization must have a psychiatric evaluation. The psychiatric evaluation should be performed by a psychiatrist familiar with the implications of weight reduction surgery. If psychiatrists with this expertise are not available, an evaluation by a clinical psychologist familiar with the implications of weight reduction surgery is also acceptable. A psychiatrist or clinical psychologist who is providing ongoing care for the patient may also provide this evaluation. Psychological testing as screening tool or as part of the psychological evaluation prior to bariatric surgery is considered not medically necessary.

II. Based upon our criteria and assessment of peer-reviewed literature, the surgical management of morbid obesity by laparoscopic adjustable gastric banding (e.g., LAP BAND, RealizeTM) is considered medically appropriate in the following circumstances:

A. The patient must meet all the requirements listed above in A-H; and

SUBJECT: SURGICAL MANAGEMENT OF

OBESITY

POLICY NUMBER: 7.01.29

CATEGORY: Technology Assessment

EFFECTIVE DATE: 05/18/00

REVISED DATE: 03/21/02, 02/20/03, 10/15/03,

11/18/04, 08/18/05, 04/20/06,

11/16/06, 11/15/07

PAGE: 2 OF: 14

Proprietary Information of Excellus Health Plan, Inc.

A nonprofit independent licensee of the BlueCross BlueShield Association.

B. The dietary history does not include a large consumption of high caloric liquids (e.g., milk shakes) or sweets; and

C. The patient has no significant history of esophageal or gastric disease (please note contraindications to adjustable gastric banding listed in the rationale section); and

D. The patient must participate in a pre-operative bariatric program that requires a 5% weight loss to demonstrate commitment to behavioral and dietary changes. The 5% weight loss will be measured from the date of the patient’s initial visit to the bariatric surgeon to the date of the request for pre-authorization of the adjustable gastric banding procedure.

You are awesome!!!!!!!!!!!!!!!!!!!!!

Thank you! I went to the BC of CA and found what I needed. According to that profile and the fact that I am going to a COE, I should be ok. We will see....keep me in your thoughts and I will keep you in mine! Best wishes.

Christy :woot:

Edited May 18, 200818 yr by CCluvs2scuba
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I have had nothing but T-R-O-U-B-L-E since I started dealing with BCBS of IL. Good Luck to you!