Blue Shields of California - HMO/Gastric Sleeve/The Process

Hi, I am new to the forum and hope that I can receive some valuable information/suggestions/ etc regarding the following information I received from my insurance provider Blue Shields of California. I requested the approval requirements to be approved for surgery and this is what they emailed me:

Prior Approval Requirements:

• Benefits for the surgical treatment of morbid obesity, performed on an inpatient or outpatient basis, are subject to the following pre-surgical requirements:

o Diagnosis of morbid obesity for a period of 2 years prior to surgery

o Participation in a medically supervised weight loss program, including nutritional counseling, for at least 6 consecutive months occurring within the last 18 months prior to the request for bariatric.(Note: Benefits are not available for commercial weight loss)

o Pre-operative nutritional assessment and nutritional counseling about pre- and post-operative nutrition, eating, and exercise

o Evidence that attempts at weight loss in the 1 year period prior to surgery have been ineffective

o Psychological assessment of the member’s ability to understand and adhere to the pre- and post-operative program, performed by a psychiatrist, clinical psychologist, psychiatric social worker, or psychiatric nurse

o Patient has not smoked in the 6 months prior to surgery

o Patient has not been treated for substance abuse for 1 year prior to surgery

 

My questions are:

- Does anyone else have BS and if so what this the requirement

- When it says benefits are not available for commercial weightloss, does this mean that I can't share my previous attempts of weightloss through Weigh****chers? or for these new found Weight Management facilities?

- If my doctor has not diagnosised me as having Morbid Obesity in the past 2 years, is this insurance language for saying "has the doctor noted your weigh-ins for the past 2 years?

- Can my primary physician put together a "medically supervised weight loss program" or do I have to pay the up-hill of $500-600 for these weight management programs?

- Does the Bariactric Surgeon provide the pre-and post operative nutritional, pych, eating and exercise assessments?

 

I have completed the online seminar conducted at ALSA in Fresno CA and was told by one their representatives that I will need a referral from my primary doctor as well as a pre-authorization before having a consultation. 

Has anyone gone through the process with the same insurance plan or have had their surgery with ALSA? (Advanced Laparoscopic Surgery Associates)

 

I am 220pounds

Height: 5'5

My BMI is 36.6

Comobility: Hypertension

Possible Unknown Comobilities: Pre-Diabetes, Sleep Apnea

It doesn't really matter if someone else had this requirement or not.  This is the requirement of your policy.

You can share your previous attempts at  Weigh****chers. But you will still have to do a medically supervised diet - WW won't count - and your insurance won't pay for a program like WW.

If your medical records show you've been morbidly obese for two years, that's all you need.  Doesn't matter if your doctor wrote "morbid obesity" in the chart or not.

Yes, your PCP can supervise your weight loss program.  Typically you just need to be seen once a month to discuss diet and exercise.

Surgeons don't do psych evals and usually don't do nutritional assessments, either.  You need to see a mental health professional for the psych eval and a registered dietician for the nutritional assessment.

My surgeons office does everything in house. They have two nuts on staff. They gave me a list of mental health people who they all work with. I met with the nut once a month and all the other people in the office. I have to agree though that every insurance is different you must check with your own.