Question:
empire BC/BS requirements, What are they? how can I find out what I need to get in
order? They already todl me there isnt an exclusion , I need a med ness,which I have,they also need a pre-cert... but what else do I need? I cant seem to find any info on the website, Please Help me I have been trying to get this surgery for 6yrs and this is my first big break and I want all my ducks in a row Kim {fl} — witchywoman (posted on August 1, 2006)
August 1, 2006
Well basically I would contact the insurance company just to find out what
they look for. Most companies require a 6 month min controled diet, and
some companies are now asking for a year long diet. This diet must be
controled by a PCP.
Good Luck
— Steve Cohen
August 1, 2006
I had my surgery June 29th and I am a bc/bs client. I needed the following
things to be approved:
1. Medical diagnosis from the perspective surgeon
2. A letter from my pcp stating that the surgery is medically necessary,
treatment process for more than 1 year (all of my weight loss trials), and
that your pcp approves of the surgery
3. A letter from a nutritionist
4. A letter evaluating your mental state from a therapist
Hopes this information helps. It took 3 months for my approval.
— nycysiti
August 1, 2006
Kim,
Usually whatever surgeon you use, their insurance person will already know
what it is you need and will tell you. My surgeon gave me a list of all
the things I need. The only thing the surgeon asked from my PCP was my
medical history and the weight loss records she has been keeping on me
since December. Find you a surgeon that is on Empire BC/BS and make an
appointment to see them. Some bariatric clinics require potential patients
to come to a seminar prior to making an appointment with the surgeon. They
have a person there that will go over with you everything you will need to
gain approval. I have Cigna and I performed a search on their website
using the keyword bariatric and they have a position paper and in that
paper it tells of requirements have to be met in order to have the surgery.
— the7thdean
August 1, 2006
When I had my surgery in June of 2005, I had empire BC/BS. They required 6
months of documented Dr Approved Diet, Documented weight gain/loss over 6
months (via Dr), Medically approved statement from Primary Dr,
Psychological evaluation (was 2 part). Once all that was done and all the
other tests that was required, I was approved within 1 week of my surgeon
submitting my paperwork to the insurance company.
If you have any other questions, feel free to email me privately
— mzb2u
August 3, 2006
Thank you so much for your answers to this question.
— witchywoman
August 4, 2006
Look for clinical guidelines for bariatric surgery on your insurance
website, or call them and ask them to send you a copy of their clinical
guidelines for the surgery. that should tell you all you need to know.
— Novashannon
August 8, 2006
I have Empire BCBS I can tell you that their website is out-dated and does
not include all of their criteria. You must have a 6 month medically
supervised diet (no break in diet) if you skip a month you start over, a
referral from your PCP saying it is medically necesassary and the following
Medical Appropriateness Criteria for Pre-authorization or Claim Review
In order to consider payment of surgery (CPT 43842, 43846 and 43847) for
obesity the patient:
1. must be at least 100 pounds over ideal weight as defined by the
Metropolitan Life Tables or has a body mass index exceeding 40 kilograms
per meter squared (see tables that follow);
OR
2. must have a body mass index over 35 kilograms per meter squared and a
clinically serious comorbidity such as obstructive sleep apnea,
hypoventilation, diabetes, hypertension, osteoarthritis, coronary artery
disease, severe hyperlipidemia or musculoskeletal dysfunction,
AND must meet all of the criteria below
has failed to lose weight significantly or has gained weight despite
compliance with a multidisciplinary medically supervised non-surgical
weight-loss program including prescription obesity medication, a very low
calorie diet, supervised exercise, behavior modification and support; AND
has no specifically correctable cause for obesity (secondary obesity)
— SassySteph
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