Question:
has n e 1 been approved on just family history and high chlestrol only by BC/BC
I have BC/BS PPO and i have high chlolestrol and back pain and knee apin but my family history is all diabetes,high blood pressure and heart disease..i was just wondering cz i'm worried about getting approved...thx in advance and haop all have a nice weekend.. — carolyn1970 (posted on April 3, 2009)
April 3, 2009
Well, having a family history of obesity and health-related issues helped
me state my claim. However at the end of the day, it was based on my BMI
and their set minimum amount of years of obesity before I got approved. I
was denied once, though, and then approved within a few months, so keep
your head up. (My reason for denial was I only had 4 years of history of
being overweight and then a few months later I was able to count 5 years.
That was the only thing that held me back.)
— poodie
April 3, 2009
Like the first poster said candidacy for surgery is based on your BMI
first. You must be obese or morbidly obese to qualify. The definition of
these two conditions is established by the National Institutes of Health
(NIH). The insurance companies make their policy requirements regarding WLS
around these NIH guidelines, not their own. But to be considered as a
candidate for WLS and determine your approval potential carefully read your
insurance company's medical policy. I have BCBS of Illinois, also a PPO
plan, and their candidacy criteria is you must have a BMI of at least 35
and two comorbidities, OR a BMI of 40 or more. No comorbidities are
required if your BMI is 40 and up. Again, these criteria are based on the
NIH guidelines for candidacy only. More than likely you will have other
requirements to fulfill like a 6-month doctor supervised weight loss
program, psychological and nutritionist evaluations. Check with your
company's HR dept too to make sure your company doesn't have separate
criteria as well; they can have riders to individualize their policies and
you may not have to go through as many "hoops" as they say.
Also, don't get discouraged if you get denied the first time. BCBS has a
reputation of automatic denial irregardless of meeting all the
requirements. Go read the insurance boards here on OH. I am in the appeal
stage myself right now. Good luck to you and keep posting here as you
journey on. This is a GREAT website with super knowledgeable folks.
— Arkin10
April 4, 2009
— ads2e
April 4, 2009
I had a BMI of 35 (just barely) joint pain, herniated disks in my back, and
gerd. I too have BC BS PPO. I felt my chances were not good as far as
getting approved. Therefor I did my homework. I got letters from
surgeons, my OBGYN, my foot doctor (he had to preform surgery on my foot
for plantar faciatis) and of course my PCP. I even wrote a letter from me
to my insurance co. I read as many books and as much information I could
get my hands on. I was even prepared for an appeal. I also had family
history of obesity, heart disease and high blood pressure. I truly
believe there is no "cookie cutter" reason they cover or don't
cover this procedure. Good Luck Kimberly
— kfgates
April 7, 2009
Best of luck, I had BCBS of Florida and ALL WLS were Plan Exclusions so I
was a self pay. Hope you can get them to pay.
Dawn Vickers
— DawnVic
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