Question:
Can someone give me any information about BC/BS?
I have already started the process with my old insurance company Cigna PPo. I just recently found out that the company I retired from is switching to BC/BS PPO as of Jan 1st 2003. What are the requirements from this new company? I have so many co-morbidities but what about stuff like diets. I am so upset about this change that I've kinda just put the brakes on the whole thing. I've already had my initial consult with my surgeon and was hopeing to have surgery, like he wanted before the 1st of the year but that's definetly not going to happen now. I also have Medicare as my secondary insurer. any thoughts would be appreciated. Thanks, Claire — gramof3 (posted on December 22, 2002)
December 22, 2002
Claire - Unfortunately this is impossible to answer because not all BC/BS
policies are created equal. I consider myself a BC/BS expert related to my
policy, as I have been to war and won with them a number of times. Many
things factor in like is it a standard BC/BS policy or has your employer
modified the policy and added or excluded some things.<p>I'm going to
give you my gut reaction based on the little information you have provided.
Because the plan you are going to is a PPO there is a good chance it is a
covered procedure as long as your employer did not exclude it. The best
place to start is to look in the exclusions section of your benefits
booklet. There usually is a statement in there about no coverage for
treatment of weight loss etc. etc. But then the exclusion goes onto say
except in the case of morbid obesity and disease etiology (co-morbidities).
This is the open door you want to look for. This says under the right
circumstances it will be covered. Assuming your policy has that exclusion,
then the next thing to do is contact customer service and find out what
they require for approval review.<p>They will require a psych eval,
letter of medical necessity either from the surgeon or your PCP, listing of
what weight loss attempts have been made and their success, and most likely
will be looking for at least 1 physician/diet center supervised attempt at
weight loss, although they did not say it quite that way to me. They also
will require an after surgery treatment/weight loss/exercise plan that the
surgeon can provide. They want to know that you will be followed and there
are expectations etc. It is important that they know that you have tried a
few times and also what other medical conditions are severely affected by
the weight. They require the obvious things of morbid obesity - 40 BMI and
100lbs over.<p>My letter just went in at the end of last week. I
know it is a covered procedure and that I qualify but am not 100% sure if
the documentation of weight loss attempts will be an issue. I have some
physician supervised attempts like from Redux and Xenical and also using
Wellbutrin to curb my appetite the last 7-8 months, but I'm not sure how
they will feel about the Wellbutrin. The Xenical I only did for 2 months
as I could not tolerate it. The Redux qualifies but that is 5-6 years back
already and if you go back to 94/95 I have 13 months of documented 200 lb
weight loss and then obviously gained it back over the past years. I'm
hoping it will go smoothly.<p>You definitely need to pursue it. Even
if it is clearly excluded, if you have the pieces of info to support your
case file an appeal. You have nothing to lose. If they cover treatment of
morbid obesity, worst case scenario should be that they want you to try a
physician supervised weight loss program first, which they will pay for
because it relates to morbid obesity. I got them to pay for Redux
medication and all associated tests and physician visits, so I know it can
be done. Good Luck!
— zoedogcbr
December 22, 2002
I have Blue Cross PPO and I had no problems getting them to pay for my
surgery. I have a lot of info on my profile if you want to check it out.
Basically I got approval for surgery in three days without any
co-morbities. My policy did have an exclusion for WLS etc. but Morbid
Obesity is considered and exception to the exclusion so everything was
covered. Just make sure on all of the tests that you have done as a pre
op, the Dr. codes them as 278.01 which is morbid obesity and then the
insurance will pay for everything. Good Luck. Wendi Open RNY 9/19 down
70lbs
— lovemonterey
December 22, 2002
This is one of those questions that no one can really answer for you.
Chris says she needed a psych eval. I have Anthem BC/BS of Colorado PPO
and did not need one. I did not have a hard time getting approved, but I
did need 5 years of documented weight loss attempts. What you will need to
have/document depends on your policy. Unless someone else works for the
same employer you do, in the same state, you can't really get a definitive
answer. Get a copy of the employee handbook as soon as you can and read it
to find out if they cover it, and if so, what criteria they have before
they will approve.
— garw
December 22, 2002
I think the psych eval may even be a state mandated thing in some states.
Both my surgeon and BC/BS said I must have it. The surgeon knew I had a
history of depression, although it is his standard policy, but BC/BS would
not have known so it was obviously SOP here for them. WI has a lot of
different laws than some states, so it might have been required. I know
others have indicated that certain states require it. Personally I think
it is a good thing as there are typically so many emotional things that
factor into our long history of being obese and it's best to be sure you
are able to deal with it and understand the seriousness of the surgery.
— zoedogcbr
December 23, 2002
Claire, I'm inclined to agree with Chris' post...in each state, BCBC
whether PPO, POS or otherwise operates differently. I too, consider myself
an expert to MY particular plan. You didn't mention whether it was a
federal plan or anything. Under normal circumstances, your surgery of
chioice is more than likely covered unless there are specific exclusions in
your policy by your employer. It might be a good idea to just take the time
and read through your benefits book. IF you meet the criteria, over 100% of
your ideal body weight, BMI (Body Mass Index >35 and an abundance of
co-morbidities, chances are you would be covered. A psych evaluation was
not required in my case-why? I don't know. You will also need to complete a
diet history-documented attempts at trying to lose weight but MD supervised
and on your own (with proof). Another good idea is to make sure that the
surgeon you decide to go to has a good aftercare program. My surgeon
provided all of that including a psychologist if necessary for additional
*coping* adjustments. Again, take time to go over your benefits package
with your Human Resource Department, ASK QUESTIONS of whomever is in charge
there, AND call the BCBS plan where you live. Be SPECIFIC in asking your
questions and be persistent. Don't give up~~since Medicare is secondary and
another option, call them and request information if you are not sure. Be
proactive and persistent~you can't go wrong! Hope this helps some!~~~
— yourdivaness
December 23, 2002
Hadiyah makes a good point about calling the insurance company's customer
service line and asking whether they cover it or not. No matter what they
tell you, ask them to send you a copy of the place in the policy to support
what they say. The person I talked to said they didn't cover it, but I
asked for them to send that to me in writing. Then I saw that it didn't
cover 'weight loss' attempts, but did cover WLS if you met their criteria.
Never take what they tell you on the phone as gospel. Get it in writing!
— garw
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