2yr dr supervised wt loss + maintain bmi of 40?

I got my ins pre-requisites from BC/BS PPO (Alliance Select/Wellmark) IA.  It reads that I must have a doctor supervised weight loss/exercise regime for the past 2 years AND maintain a bmi of at least 40 for the past 3 years.  I called BCBS and inquired about this and she couldn't give me an answer.   I have come to the conclusion that BCBS is making WLS available, but with impossible pre-requisites.  How is a person to diet/exercise for 2yrs prior to applying for surgery while maintaining a bmi of 40?  Hmmmmmm.  Available, yet not available.  Sounds like Catch 22 to me. 
I do not have diabetes, or high blood pressure, and my bmi is 45.  BCBS wants me to be on diabetic meds for at least one year (if I am diabetic), and be taking high blood pressure meds for at least one year (if i have hbp).  So, BCBS prefers one to die of heart failure or diabetes before they will approve anyone for WLS?  Wouldn't it be cheaper to PREVENT the problems? (I asked her about this as well, no answer).
Also, I have PCOS.  In 1999, my doctor told me that I should expect to gain at LEAST 10 lbs per year with this condition.  I have tried very hard not to fall into the catagory of "this happens to most people."  However, I seem to have proven the doctor correct.  I have gained this weight no matter what I have done.  So, again, WLS is available, yet not available. 
I have my first consult on Sept 4th.  I will see if the doctor can do anything, since PCOS almost guarantees weight gain and it causes diabetes eventually.

I have been doing the three month nut visits for my procedure. MY BMI was 40.8 I have lost enough for my BMI to go down to 40.1. My nut told me to maintain and try not to loose any more until I got approval. So I'm trying to maintain. She did tell me not to gain any though. So that is what I'm trying to do. I think as long as you try to loose just not go below 40 BMI.  I have my first consult with the surgeon on Monday. I will find out more info then. Skye

The WL surgeon I will be seeing is listed with BCBS as a preferred provider.  I'll just wait for my visit and see what they can do about it.  Thanks so much for your input.

I have BCBS of New Jersey and my plan requires a 6 month monitored diet.  It states that I have to lose weight or maintain for that time period (can't gain weight).   

Jillybean informed me that BCBS of New Jersey recently updated their requirements for approval and they are actually better than what I originally thought. 

Go to the website for your BCBS insurance and search for your policy manual.  Look up surgery for morbid obesity and see what they require.   What I found printed in the manual was different than what they told me over the phone.  Check it out as it may help you. 

Is this your plan's website?


http://www.wellmark.com/e_business/provider/medical_policies /policies/obesity_surgery.htm

They sent me a pages from their manual, they match their website.  Their website is wellmark.com, but not sure if it's the same as you have posted.  However, I have the papers that they mailed me, and I will take it to the dr when I have my consult and see what they have to say.  The company the insurance company is for is a trucking company, and it may be the type of coverage they contracted.... I don't know.   

Are you sure it's "for the past two years" and not something like "6 months within the past two years?" I've never heard of an insurance company requiring two full years of supervised diet.

Yes, I'm sure.  What I wrote in my first post is what BCBS sent me.  I must, PRIOR to seeking surgery, have had dr supervised weight loss/exercise program for two years AND show a past BMI history of at least 40 for the previous 3 years.   

This is what it says in the manual on Wellmark's website:

Criteria for Coverage:

• Patient is at least 18 years old

And

• The patient must have documentation in the medical record of failure to sustain weight loss within the two years preceding surgery and documentation of the health care provider’s monitoring of the patient’s progress toward a goal of weight loss.  

And

• The patient must be a motivated individual with acceptable operative risk and must be evaluated by a licensed mental health provider to determine the patient's willingness to comply with pre and postoperative treatment plans, and a strategy to ensure cooperation with follow-up must be documented.

And, in addition to the general requirements above, the patient must also meet one of the following weight criteria:

• BMI of 40kg/m² for at least 3 years  

Or

• BMI of greater than 35kg/m² in conjunction with at least one of the following:
  • Hypertension requiring medication for at least one year
  • Diabetes Mellitus type 2 requiring medication for at least one year
  • Obstructive sleep apnea, confirmed by sleep study, which does not respond to conservative treatment
  • Documented cardiovascular disease
  • Pulmonary hypertension of obesity

To me, that does not sound like you need to have been following up with your doctor every month for the past 2 years. It just sounds like you need to show that your doctor has been aware that you were trying to lose weight, and that you have failed to maintain any significant weight loss. Because it is vaguely written, I would call and ask for exact details of what specific documentation is required. Better yet, enlist the help of your surgeon's insurance expert. They know the exact questions to ask to get to the bottom of things!

Thank you.  I have documentation of dr visits going back to 2004, however, it does not state anything about trying to lose weight.  They know Ihad been trying, but I will need exact dates as the person *****searches my record charges for her time, and $5 per page for copies.  I'll leave it up to the dr's office when I go in.  Thanks again.