newbie here - first of probably many more questions

Hi folks,

I attended the seminar, filled out all the paperwork and mailed in my info.  I'm still not 100% sure on how the insurance process works.  I checked online (the rep on the phone was a joke), and it looks like this is supported.
Is this a 2 phase process? Phase one .......... surgeon verifies the insurance criteria and coverage. Phase two ......... all required info and minimums met, submitted to insurance, and they must sign off?
I just don't want to get excited about the future and then have a bomb drop.

Any information would be helpful,
Dave

Who is your insurance company? Do they have an online site that lists the policy or do you have a Human Resources director that could give you some advice? A lot of insurance companies will require a pre-op diet, weigh ins, doctor visits, etc. Where are you planning to get your surgery? 

The previous poster was right - the exact process does depend upon your insurance company.  I have Independence Blue Cross and I was required to get a referal from my PCP to my bariatric surgeon -[I had a particular bariatric program in mind when I saw my PCP regarding this].  I had to take various pre-op tests and they requested a letter from my PCP outlining my weight history, weight loss attempts and co-morbidities -if I had any.  The hospital bariatric practice I wsas part of required additional meetings - a teaching class on life with WLS, an individual meeting with a dietician and a psychological consult.   Generally speaking as you probably know, most places with require a bmi of 40+ without co-morbidities or a bmi of 35 -40 with.  This comes from a consensus statement made by the National Institutes of Health in the 1990s. After all that was done, the surgeon's office submitted the info to the insurance company and they - after a small hassle - pre-approved the procedure...after that I was given a surgery date. Depending on whether you are required to undergo a pre-surgery doctor supervised weight loss program - I didn't have that requirement - I'd have to guess the process takes anywhere from 3 months to a year to get everything done with an average of about 6 months.  I had my first consult with the surgeon October 31 and my surgery was March 10--and I was trying to do everything as quickly as possible.

Good luck to you!

Rhonda

what they said. This is a very individual process based on the persons insurance company. It is hard to say. Good luck anyway

Thanks for the info.

I have BC/BS insurance, so I "think" I'm ok. 

Here is what I found online:



Thank you for your inquiry. Surgical treatment of morbid obesity may be considered eligible for coverage when all of the physical, clinical and psychological indications are documented according to Blue Cross and Blue Shield of Illinois current medical policy. A letter of support and/or explanation is helpful but alone will not be considered sufficient documentation to make a medical necessity determination.
We are not in a position to consider the request for surgical treatment of morbid obesity due to the lack of available medical documentation to determine medical necessity based on Blue Cross and Blue Shield of Illinois medical policy. The following documented clinical information is necessary for further review.
A. A diagnosis of Morbid Obesity documented in the clinical records and must include:
* Body Mass Index (BMI) of greater than or equal to 30 kg/meter squared; OR
* BMI greater than or equal to 30kg/meters squared with at least two (2) of the following co-morbid conditions which have not responded to maximum medical management and which are generally expected to be reversed or improved by bariatric treatment:
1. Hypertension,
2. Dyslipidemia,
3. Diabetes Mellitus,
4. Coronary heart disease, and/or
5. Sleep apnea.
AND
B. At least a five-year history of Morbid Obesity supported by medical record documentation.
AND
C. It is expected that appropriate non-surgical treatment should have been attempted prior to surgical treatment of obesity.
Non-surgical treatment of morbid obesity appropriateness criteria must be documented in the records submitted and include the following:
1. Medical record documentation of active participation in a clinically-supervised, non-surgical program of weight reduction for at least 6 months, occurring within the six (6) months prior to the proposed surgery and preferably unaffiliated with the bariatric surgery program. [NOTE: The initial BMI at the beginning of a weight reduction program will be the "qualifying" BMI used to meet the BMI criteria for the definition of morbid obesity used in this policy.]
A program will be considered appropriate if it includes the following components:
1. Nutritional therapy, which may include medical nutrition therapy such as a very low calorie diet such as MediFast or OptiFast OR a recognized commercial diet-based weight loss program such as Weigh****chers, Jenny Craig, etc.
2. Behavior modification or behavioral health interventions.
3. Counseling and instruction on exercise and increased physical activity.
4. Pharmacologic therapy (as appropriate).
5. Ongoing support for lifestyle changes to make and maintain appropriate choices that will reduce health risk factors and improve overall health.
2. Documentation of willingness to comply with preoperative and postoperative treatment plans and
3. Documentation that growth has been completed (18 years of age or documentation of completion of bone growth).
Please note historical medical records corresponding to the time period you were treated for the obesity condition signed and dated by health care professionals will be considered appropriate documentation
The member and their physician(s) are urged to review the full text of the Blue Cross Blue Shield Illinois (BCBSIL) medical policy on this subject on the BCBSIL Website at www.bcbsil.com. Choose the "provider" link at the top of the Website and select medical policies: Surgery for Morbid Obesity (search by policy title).

If you have any further questions or concerns, please contact our customer service department at the toll-free number on the back of your Blue Cross Blue Shield identification card or via the Message Center on Blue Access.

Hi Dave,

I, too, have BC/BS. For my plan (every plan is different) WLS is covered as long as you go to a Blue Distinction Center for Bariatric Care. Once you find a center that BC/BS likes, then you have to find a surgeon or practice that is affiliated with that hospital.  My advice to you is to contact your BC/BS customer support and ask them about your particular hospital/surgeon that you have in mind.  They will be able to tell you if they are a preferred provider.  Also, the surgeon's office will probably have a dedicated staff member that handles insurance paperwork/submittals/appeals, etc. and they will know what insurance their office can work with.

If you do find a surgeon, they will probably have you call your insurance provider before scheduling your initial consult anyway.  It is kind of a 2-part process.  Check with the insurance and see if it's covered and then the surgeon's office will submit your case as a "package" for approval.  Your "package" will most likely consist of:
-Your PCP's support/history in the form of a letter
-Your pre-op test results showing any co-morbidities (Sleep Study, etc.)
-Your pre-op test results showing your health and that you are a candidate for surgery (Bloodwork, EKG, Chest X-Ray, Upper GI, etc.)
- Your Psych Eval
- Your 6-month (or whatever pre-determined timeframe) dieting requirement
- Your Nutritionist Consultation
- Any other documentation supporting your case for WLS

HTH!

Kelly

Welcome Dave!!!!  I do not have your insurance but I think what the others said is probably most accurate as they would know more about BCBS than me...but I did just want to say that it is great that you found the forum!!

I look forward to getting to know you as you make this journey!!  If you have any questions or concerns please feel free to post them we are a really friendly and helpful bunch!!!!

Again Welcome!!

Laura

Hi Dave-

Your surgeon's office will usually have the low down.  BCBS was easy for the RNY or Lap band, but no other WLS.
BMI of 40+
MD recommendation
Failed attempts at weight loss programs-must have documentation.

Keep copies of everthing and who you speak to.  I started a folder for my WLS journey.

I found member services at IBC very helpful.

I had BC/BS Keytone East and Barix was an in network provider. For me it was easy peasy. I had my consult wiht Barix on 6/3 and was approved on 6/9. I did not have to have documented previous weight loss attempts or a 6month diet. My BMI was 42.2 and that's all that they needed.

Even the same insurance plans have different benefits. It's a matter of did your employer purchase the caddilca of plans or the hyundai.

Good luck.