New BCBS IL Policy on Surgery

Blue Cross Blue Shield of Illinois has changed their policy on weight loss surger as of 1/18/05. Took some digging to find it, but here is the link: http://medicalpolicy.hcsc.net/medpolicies/home?corpEntCd=IL1&path=templatedata\medpolicies\surg\data\SUR716.003_2005-01-18&ctype=MEDPOLICIES-POLICY&cat=SURGERY From what I can tell, to get the surgery approved, you have to be very sick -- sick enough so that you will not make it until your surgery date. Just kidding, but the number of hoops they need you to jump through are huge for a guy my size

Hi Mitch, I tried to use your link and kept getting an error. I started about the same time you did. I never found the policy, but the surgeons office told me that BCBS IL required a full year of medically supervised weight loss with monthly weigh-ins before approving surgery. I figured by the time I got that done, they would just change their policy again. I will be getting banded 1/31 as a self pay. I am putting it on a credit card and will do the 0% interest transfer shuffle until I can pay it off. Unless there is government regulation requiring insurance companies to pay for WLS, I think most will do what they can to make the hurdles insurmountable.

You can get to the policy by going here: bcbsil.com/medpolicy (with a www. in front of it - we're not allowed to post links). You have to agree to their information policy or you won't be able to go any further. Then you find the 'surgery' category and click on it. Then locate 'surgery for morbid obesity' (you'll have to flip through the pages - but entries are alphabetical) and click on it. That will get you to the updated policy - which is the PPO policy (I believe). May be different for HMOs. This is why you have to constantly keep checking the BCBS policy on WLS. Since I've started checking they've changed the policy 4 times: 8/15/03; 4/9/04; 10/6/04 and now 1/18/05!

HI, I HAVE JUST STARTED MY QUEST TO HAVE THE LAP BAND SURGERY AND I TOO WILL BE A SELF PAY. I HAVE SO FAR RESEARCHED ABOUT THE SURGERY BUT I HAVE NO IDEA AS TO THE COSTS. CAN YOU PLEASE SUPPLY ME WITH INFORMATION, SUCH AS, WHERE YOU'RE HAVING IT DONE, YOUR SURGEONS NAME AND ALSO THE COSTS ... ANY INFORMATION WILL BE GREATLY APPRECIATED.... THANKS, LEXI PS. I WISH YOU WELL !!!!!!

Hey Lexi, Can't help you with the cost information as I'm really not sure what it will cost. I just switched to a PPO (from an HMO - where I didn't worry about cost since it was either covered 100% or it wasn't). The PPO should cover everything at least for big percentage (70% out of network and 80% in network). For my surgeon I've chosen Dr. Frantzides out of Evanston. He has done over 1000 lap RNYs, has incredible statistics with death/complication rates that are far, far, far below the national norms. He invented some laproscopic procedures and instruments and lectures and teaches procedures. I have a consult with him at the end of March. He is out of network for all insurance and requires a deposit or credit card number up front. But from what I've found in months and months of research, the single most important factor in whether there are complications or deaths with the surgery is the experience of the surgeon. So, I'm going with the most experienced I can find. By the way, if you are thinking about lap band instead of RNY, there is a separate forum / board for lap banders. You should give it a try. They will likely have more information for you on doctors, costs etc. Wish you all the best, Illini

Mitch this looks like the same thing they had before only a bit hard now to meet the requirements which you were right you gotta be really sick

Mitch, Thanks for the heads up! Looks like it's not too different from the previous (10/6/04) version - am having a hard time spotting exactly what they changed. Did see that they added: "Evaluation of psychological comorbidities that contribute to weight mismanagement; and/or eating disorder." to the psych eval. Wonder what exactly that means? And, what else did they change? Illini

The big change is that the psyche eval has to be done by an independent Dr. (one not affiliated with the surgical group). "Evaluation of psychological comorbidities that contribute to weight mismanagement; and/or eating disorder" - They want to make sure that you do not have anything going i.e. bulimia, and that there are deep seated reason for not being able to loose weight. Miss Avery

OOPS! that there are NO deep seated reason for not being able to loose weight. Miss Avery

Thanks Miss Avery! Have been steadily slogging my way through the requirements especially the 1 year physician supervised weight loss plan part (I'm half way through). Am very afraid of the moving target that BC/BS keeps putting up there and have been monitoring the requirements pretty closely. The hardest part of all this is being patient. Illini