I received a letter in the mail yesterday from BCBSM with the information that was provided to me over the phone earlier this week. I know that many BCBS plans are different, but I thought I'd share what my letter stated as far as coverage is concerned for bariatric surgery.

 

P.S. - I have Blue Cross Blue Shield of Michigan - Community PPO

 

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Gastric Bypass / Adjustable Gastric Banding Surgery

 

Fact Sheet

 

Approved bariatric surgical procedures, including sleeve gastrectomy, are considered established for the treatment of morbid obesity if all of the following criteria are met:

 

• The patient has a body mass index greater than 40, or a BMI of greater than 35 with comorbid (accompanying) conditions such as degenerative joint disease, hypertension, hyperlipidemia, coronary artery disease, presence of other atherosclerotic diseases, type 2 diabetes mellitus, sleep apnea or congestive heart failure.
   
• Risks and benefits of the planned surgery, including those related to the patient's age, should be documented in the clinical record. BCBSM has no age requirements for bariatric surgery for adults.
   
• The patient must be clinically evaluated by an M.D. or D.O. The physician must document, in the medical record, the failure of non-surgical efforts to lose weight. The document must include that the patient participated in a structured, professionally supervised (physician or non-physician) weight-loss program for a minimum of six consecutive months within the last four years prior to the recommendation for bariatric surgery. (The requirement to participate in a weight-loss program is waived for super morbidly obese individuals who have a BMI greater than 50.) Documentation also should include periodic weight, dietary therapy and physical exercise, as well as behavioral therapy, counseling and pharmacotherapy, as indicated.
   
• The surgeon should document that the patient understands the benefits and risks of the available surgical and non-surgical management strategies. This documentation also must include an informed decision to proceed with bariatric surgery with an understanding of the surgical risk and the commitment to medical management thereafter.
   
• A contracted mental health professional must perform a psychological evaluation prior to the surgery to establish the patient's emotional stability, ability to comprehend surgery risks and to give informed consent, and ability to cope with expected postsurgical lifestyle changes and limitations. This consultation may include one unit of psychological testing for personality assessment (for example, the MMPI-2 or the adolescent version, the MMPI-A).
   
• The physician should arrange follow-up with the patient to monitor for any long-term complications occurring as a results of gastric surgery.

 

In cases where a revision of the original procedure is planned, documentation of all of the following is required:

 

• Date and type of previous procedure
   
• Factors that precipitated failure
   
• Complications from the previous procedure that affect the patient's inability to maintain the weight loss. If the indication for the revision is a failure of the patient to lose a desired amount of weight, then the patient must meet all of the initial preoperative criteria.

Are you limited to certain surgeons? If they don't have a list of approved surgeons, start doing your research and find a surgeon. Call their office and ask if the take Medicaid. If they don't, ask them for a referral. Once you find a surgeon, they will put the rest of the plan in place. Good luck!

Just starting process of trying to get wls, has anyone actually gotten approved and had surgery in Nevada?  I need any help I can get.

Hello there, So today I started two additional medications and now up to 8. This is for blood pressure, diabetes and not sure what else they are trying to control except for these two things.

I have the support of my regular doctor. I went to see a cardiologist to make sure I was healthy enough for the surgery and that my heart was in good shape. This doctor is also a  true believe and feels I am an excellent candidate. We contacted OWLLS and were told that the insurance will not pay for it. I do have an exclusion for weight loss surgery. To get around this I was told to have everyone go in with angles of all the needs to be done to remedy what is wrong.

I have never gotten a letter from anyone saying NO. I only get this over the phone. How does a person get past the main people answering phones? Get someone to look at all the records?

 

Anyone in Oregon know any way to get around this or some advice?

Thank you,

Dean

 

I hit the 40 mark This past year. Keeping my fingers crossed.