Blue cross of California

Please can somebody tell me what there requirements are for gastric bypass i cant seem to find it on there website Please Help.

There are so many different surgeries.  Get informed about all of them and then go from there.  I can't tell you what the requirements are for each one.  You might want to call your insurance company and talk to them and maybe they can recommend a doctor for you, where they could help you out.  There is Roux en Y surgery, Lap band, Dueodnal Switch, Gastric Sleeve and I think I am missing one.  Try looking on the web for each one and do research.  I was stuck on having the lapband, but I needed to lose over 200 lbs and needed to lose it fast due to health complications, so I opted for Roux en Y (RNY).  Never regretted a moment.

Good luck, and ask any question you need to, and welcome to the RNY California Board.

Diane

See with Aetna I was able to view there requirements online  and with my new insurance which is Blue cross of California I seem not to find it online. 

Ok here it is its pretty standard
http://www.anthem.com/ca/medicalpolicies/policies/mp_pw_a053 317.htm

This is the anthem blue cross policy. 

Subject:	Surgery for Clinically Severe Obesity
Policy #:	SURG.00024	Current Effective Date:	04/16/2008
Status:	Revised	Last Review Date:	02/21/2008

---

Description/Scope

Clinically severe obesity is a result of persistent and uncontrollable weight gain that constitutes a present or potential threat to life. There are a variety of surgical procedures intended for the treatment of clinically severe obesity. This document addresses those procedures.

Policy Statement

Medically Necessary:

Gastric bypass and gastric restrictive procedures with a Roux-en-Y procedure up to 150 cm, laparoscopic adjustable gastric banding (for example the Lap-Band^® System or the REALIZE™ Adjustable Gastric Band), vertical banded gastroplasty, or biliopancreatic bypass with duodenal switch as a single surgery, is considered medically necessary for the treatment of clinically severe obesity for selected adults (18 years and older) who meet ALL the following criteria:

1. BMI of 40 or greater, or BMI of 35 or greater with co-morbid conditions including, but not limited to, life threatening cardio-pulmonary problems (severe sleep apnea, Pickwickian syndrome and obesity related cardiomyopathy),  diabetes mellitus, cardiovascular disease or hypertension; AND
2. The patient must have actively participated in non-surgical methods of weight reduction; these efforts must be fully appraised by the physician requesting authorization for surgery; AND
3. The physician requesting authorization for the surgery must confirm the following:
   • The patient's psychiatric profile is such that the patient is able to understand, tolerate and comply with all phases of care and is committed to long-term follow-up requirements; and
   • The patient's post-operative expectations have been addressed; and
   • The patient has undergone a preoperative medical consultation and is felt to be an acceptable surgical candidate; and
   • The patient has undergone a preoperative mental health assessment and is felt to be an acceptable candidate; and
   • The patient has received a thorough explanation of the risks, benefits, and uncertainties of the procedure; and
   • The patient's treatment plan includes pre- and post-operative dietary evaluations and nutritional counseling; and
   • The patient's treatment plan includes counseling regarding exercise, psychological issues and the availability of supportive resources when needed.

Surgical repair following gastric bypass and gastric restrictive procedures is considered medically necessary when there is documentation of a surgical complication related to the original surgery, such as a fistula, obstruction, erosion, disruption/leakage of a suture/staple line, band hermiation, or pouch enlargement due to vomiting.

This is some of the policy.  I am sure this is the part that you are interested.

Good Luck
Liz





 

BC of Calif. approved me for lap band and RNY.  I had to meet the BMI requirement (35 for me because I also have diabetes type I).  No diet history required, no pre-surgery diet or weight loss required.  You'll have to go to a center of expertise, not just any WL surgeon.  They made me travel 3 hours when I had a great one here at home.  The local guy is doing all my follow-up though.  Good luck.

Hi! Did you have hmo? if so, where you are sent is generally determined by your medical group...not the insurance. I knew Monarch medical group refered to my surgeon, so I switched to a PCP that was in that group. (It took a lot of phone calls to find a PCP that seemed amicable to the idea of wls.)

Just wonderin'

Rachel

I have EPO I think it is similiar but not sure.

I have BC Cali. When I got my approval...5 years ago, they told me over the phone, it had to be "medically necessary." It took about 5 phone calls to get the details (that have been outlined in a earlier post). BMI of 40 or 35 w/comorbids. I did not have to prove I was on a medically supervised diet (though I recommend it before surgery).

If you are on an HMO, your medical group will have to approve it before sending it to the insurance. When I had Cigna, my PCP and med group seemed down on WLS and denied me. I appealed to my insurance without a problem.

Rachel

I am confused I was looking at my insurance card and it says PPO on the bottom right hand side but when I called they told me my plan is EPO and that I dont have to get referrals for any services and with Aetna my pcp needed to get referrals 

Hi again,
That is confusing. If you have EPO is kind of like a hybrid of PPO and HMO. With EPO, you don't need a referral (similar to PPO), but you have to stick within the network pull of doctors (similar to HMO). The pull of Dr's in and EPO is generally smaller than an HMO to keep the premiums lower.

Do you have a book of dr's/surgeons with in your EPO network. You may be able to request a surgeon that is better suited for you (or you may find the one they referred you to is the only one avialable.)

Did that make any sense at all?

Rachel