Question:
What exactly is the critera for surgery?

I have made several calls to my 800# and spoken with several reps and they keep telling me "medical necessity." They tell me the provider must call them and see if I meet the approval criteria. What I want to know is what the heck is the "approval criteria?" I don't understand why they just can't tell me - I'm the one having the surgery.    — JENNIFER K. (posted on February 3, 2003)

February 3, 2003
Call back and ask for the approval criteria, and when they say " must be medically necessary", ask what other criteria is used. I don't know why they won't tell you, other than the folks you have talked to may not have that information. Ask if they use the NIH 1991 Concensus Statement as criteria. If they say, "What's that?" it's a pretty good bet they have no idea what the criteria is. Or they are not the brightest bulbs in the hallway, if you know what I mean. It is the surgeon's office that will be calling to get approval. (Whoever wants to be paid is the one that calls for approval.) Did you try the library on this site to see if your insurance is listed? You might find some info there. Good luck!
   — koogy

February 3, 2003
Your plan might be different, but I have BC/BS Fed and the criteria is a BMI over 40 (100 pounds or more overweight) and a history of dieting attempts, to include a doctor supervised diet. Most of the insurance companies require th BMI of 40 or higher, or 35-40 with co-morbidities (like high blood pressure, sleep apnea, diabetes to name a few).
   — Cindy R.