Question:
Has anyone been approved who has BC/BS of Pennsylvania?
If so, what was their requirements? — tanyad50 (posted on April 30, 2008)
April 30, 2008
I had BCBS of Florida and all WLS are plan exclusions. I was a self pay.
Check your Plan booklet under exclusions, call the 1-800# and ask what
their policy is and check it out thoroughly so you can be well informed.
Good luck,
Dawn Vickers, RN, BLC, CLC
— DawnVic
April 30, 2008
Are you part of Highmark BC/BS? If so:
Patient Selection Criteria
"The patient is morbidly obese;
Morbid obesity is defined as a condition of consistent and uncontrollable
weight gain that is characterized by a weight which is at least 100 lbs. or
100% over ideal weight or a BMI of at least 40 (V85.4) or a BMI of 35
(V85.35-V85.39) with comorbidities (e.g., hypertension, cardiovascular
heart disease, dyslipidemia, diabetes mellitus type II, sleep apnea).
The patient is at least 18 years old; and
The patient has received non-surgical treatment (e.g.,
dietitian/nutritionist consultation, low calorie diet, exercise program,
and behavior modification) and attempts at weight loss have failed.
The patient must participate in and meet the criteria of a structured
nutrition and exercise program. This includes dietitian/nutritionist
consultation, low calorie diet, increased physical activity, behavioral
modification, and/or pharmacologic therapy, documented in the medical
record. This structured nutrition and exercise program must meet all of
the following criteria:
The nutrition and exercise program must be supervised and monitored by a
physician working in cooperation with dieticians and/or nutritionists; and
The nutrition and exercise program(s) must be for a cumulative total of 6
months or longer in duration; and
The nutritional and exercise program must occur within two years prior to
the surgery; and
The patient's participation in a structured nutrition and exercise program
must be documented in the medical record by an attending physician who
supervised the patient's progress. A physician's summary letter is not
sufficient documentation. Documentation should include medical records of
the physician's on-going assessments of the patient's progress throughout
the course of the nutrition and exercise program. For patients who
participate in a structured nutrition and exercise program, medical records
documenting the patient's participation and progress must be available for
review.
The patient must complete a psychological evaluation performed by a
licensed mental health care professional and be recommended for bariatric
surgery. The patient's medical record documentation should indicate that
all psychosocial issues have been identified and addressed.
Patient selection is a critical process requiring psychiatric evaluation
and a multidisciplinary team approach. The member's understanding of the
procedure, and ability to participate and comply with life-long follow-up
and the life-style changes (e.g., changes in dietary habits, and beginning
an exercise program) are necessary to the success of the procedure.
If the patient does not meet all of the patient selection criteria for
bariatric surgery, the procedure will be denied as not medically necessary.
A participating, preferred, or network provider cannot bill the member for
the denied services."
— nursenut
April 30, 2008
I had Highmark BC/BS and besides being 374 lbs....isn't that enough
criteria, lol, all I had was borderline high blood pressure and asthma
which was just diagnosed the year before, so it was pretty easy for me.
They required the 6 month weight study with the doctor but my doctor pretty
much waived that and used the prior visits I had made and went off that, he
thought that the insur. companies required too much of people to have the
surgery. I had the psych eval and that was pretty much it. There was no
weight requirement or had to have so many ailments, no I went in told my
doctor I wanted to have it done and he was on board with me. I met up with
the surgeon and had all of the blood work and x rays needed and was
scheduled for surgery. Hope this helped and good luck.
— PAWLLA L.
April 30, 2008
I live in PA, I have BC/BS I think it is called "access care II",
I have no idea,,,but yes, I was approved to have the surgery AFTER meeting
ALL of their criteria, & I had my surger on April 17th of this month.
I am recovering well, however, I did not receive any bills yet. I know
there is a $2,000 co-payment as per my particular plan, but I'm not sure
about the co-insurance, or if there even is one, I think the $2,000 is it,
but who knows with insurance companies these days,,,,let me tell you how to
view the "criteria" on line on their website,,go to
www.bcnepa.com,,,,along the top are the headings, VISITORS, MEMBERS, GROUP
ADMIN, PROVIDERS,,,,click on PROVIDERS,,,then go to medical policies,,&
find the one for morbid obesity & there you have all of their
ridiculous criteria that you must meet, I also had to join a 6 month
program at Lehigh Valley Hospital (to the tune of $400) in order to have
the surgery there by my chosen surgeon (Dr Peter Rovito in
Allentown-EXCELLENT) I would only recommend surgery if you were to go to
him,,,hes fabulous! Anyway, I didn't find it too hard to prove those
things,,,,hell, 2 of the 3, 6 month long diets I was on, were when I was an
adolescent/teenager. The most recent one being at Lehigh Valley Hospital.
If your family doctor is not against WLS in general, you should be fine!
if you need any help,please let me know!!!!!
oh, yes, I don't know if you are a smoker, but I had to quit & THEY DO
test you prior to approving your surgery!!
Denise
— [Deactivated Member]
May 1, 2008
Hi, I have BC/BS of PA, actually Personal choice. My surgery was approved
in about 15 days even before I had any pre-surgery tests. I have diabetes
and other co morbidities, but their criteria are age up to 65, 100 pbs
overweight, comorbidities etc.
— SkinnyLynni2B
May 1, 2008
Hello,
I have Personal Choice (part of BC/BS of PA) and my surgery was approved
within a week of submitting to the insurance co and I had no
co-morbidities, just a bmi of 41 and 100+ excess weight. I had the surgery
in Dec '07 and the only deductible I had to pay by my plan was $75/day for
the hospital and I was only in 2 days for the RNY lap. I also did not have
to do the 6 months diet supervision. So my entire pre-op and then approval
processes went extremely quick.
Good Luck!
— jenndolyn
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