BlueCross BlueShield is Waking the "F" Up!

Aug 14, 2009

I'm not sure if this has already made it out there, but I heard from "behind the scenes" the other day that this could possibly be happening. I did not post it because I did not have the proof in my hand. Well now I have it. Now understand that I was just denied last month because the BPD-DS was considered "investigational" by BlueCross BlueShield of Alabama. Well they have officially changed their stance. They now cover the DS. There is a +50 BMI catch to it, but as anybody that has dealt with "demsumbitches" will tell you, this is an enormous leap in the right direction. I also heard that this is possibly part of a new national stance by BC/BS. Below is exactly what their policy states now regarding the DS. I hope some of you get some real pleasure in this. I know I did. Now if we can just get them to wake the "F" up about that +50 BMI bullsheet. Oh well. Tiny victories.....

Malabsorptive Procedures: Open or laparoscopic biliopancreatic bypass (i.e., the Scopinaro) procedure with duodenal switch meets Blue Cross and Blue Shield of Alabama’s medica criteria for coverage for treatment of the morbidly obese patients with BMI of 50 kg/m2 or more when the following criteria are met:

1. Documentation must be present of participation in medically supervised weight loss program. For purposes of coverage, we (BCBS) recognize medical supervision of the diet and activity program by practicing MD's who are not bariatric surgeons, such as family practitioners, internists, and other primary care specialties. Documentation provided by these health care providers will be recognized in the review process. At least one attempt must occur during the one year prior to request for surgery or date of surgery. Documentation must support participation in the program for six consecutive months. The following criteria must be met for this participation:

a. Documentation of participation in a physician supervised program of nutrition and increased physical activity (including dietitian consultation, low calorie diet, increased physical activity and behavioral modification). Documentation of program participation must appear in the medical record by the attending physician. Documentation should include comments by the physician regarding

patient progress or lack of progress. A letter does not meet this requirement. There must be medical records to document medically supervised weight loss attempts;

OR

b. Acceptable with medical record documentation of medical supervision are: Weight Watchers, LA Weight Loss, Jenny Craig, EatRight etc. Not acceptable are self-directed programs such as joining a gym, Atkins’ diet, calorie counting, low fat, cutting back, internet programs, etc.

2. A complete history and physical must be performed by the bariatric surgeon to include height and weight.

3. The patient must be at least 18 years of age.

4. Due to the surgical morbidity associated with concomitant pulmonary disease coverage will not be provided for anyone who has smoked in less than eight weeks prior to surgery

0 Comments