BCBS-PPO of Mi policy

I live in Missouri so I have no one else here that has my policy. It took me awhile to get them to send it to me. I have been on my 12 month supervised diet since November 05'. I did miss Dec. and Jan. so I am afraid that will be one problem. Also I am worried there is not enough written in my doctors charts. My policy on the diet follows.... The patient has been clinically evaluated by an MD or DO. The physician has documented failure of non-surgical management including a structured, professionally supervised (physician or non-physician) weight loss program for a minimum of twelve consecutive months within the last four years prior to the recommendation for Bariatric Surgery. Documentation should include periodic weights, dietary therapy, and physical exercise, as well as behavioral therapy, counceling and pharmacotherapy, as indicated. Can anyone let me know exactly what should be written in my charts monthly? What about the behavioral therapy? Will the two missed months mess me up? Thanks!! S Goodman

Blue Cross took the letter my doctor sent and it was ok. I didn't see her every month (every 3) but each had a blood test that included the A1C which showed if I was good or not. She also kept track of my weight every 3 months and we talked about the diet and how it was going. I've been going to my doctor for the past 15 years so there was a lengthy history on the ups and downs of dieting. If you've been with your doctor for a while, have him/her write a letter that answers all the questions that BC/BS wants.

Ann thanks for the reply. I actually had to switch PCP's in November when I started my diet. The one I had for years was not supportive of me wanting the surgery at all. The PCP and NP I see now are extremely supportive and I will talk to them at my next visit regarding my charts. Thanks!! Shonna

Your new PCP should be able to get all your records from your old PCP and then put together a letter from them.

Shonna, I have BCBS of MI PPO and was switched to this plan January 17 2006. I immediately called when I got the letter things were changing (received letter Dec. 2006). I was told that it would be covered if the doctor said I met the criteria for surgery. Beyond being over 40 on BMI I am not sure of the other specifics but my doctors office new and said I qualified. I didn't do months of weightloss or anything like that. I received my surgery April 19th 2006 and other than deductibles things have been covered. I think this is a very big opportunity for you. I had the DS and have loved the results. I have lost 91 pounds. In 5months and 11 days. Please feel free to email me if you have any other questions. Best Wishes!

I have BCBS PPO of Mi as well. I'm still in the pre-op process and currently fighting with my PCP office to actually figure out what it means when I say "Send a copy of my file". Duh! Anyway, I've called BCBS twice abbout this issue because I'm getting conflicting information from the surgeon's office. My surgeons office says I need to have monthly appointments to track the diet history. BCBS says that it needs to be tracked by the doctor during a 12 month period, but monthly visits are not necessary. They say that as long as the information is documented in my chart that my 3 visits throughout the past year is fine. I've kept track of every conversation I've had with everybody - I write down who I speak to, the date/time and what number I called to get that person. Then I also pre-write my specific questions and try to write as much of exact quotes as I can after the call so I have a record of what I've been told along the way. I've been told records like this will help if I ever need to go into the appeal process. What has also helped me a lot is getting the exact procedure and diagnostic codes from the surgeon's office. This has helped me ask specifically what is required for each procedure to be covered. Keep us posted. Pam

Thanks Pam! Has anyone told you what needs to be written in your Drs Charts?? To get copies of my charts I went to the office and signed a paper to get copies. My surgeon requires everything to be hand delivered to him so nothing gets lost. Shonna

Hi Shonna, I have BCBS PPO , MI . My PCP wrote a letter saying it was a medical necessity that is all I needed. I had surgery on 4/6/06. Were ever you are having surgery should be able to guide you on what you need to do. My surgeons office did all that for me, i filled out the paper work, they did the rest. Good luck to you. DeAnn 261/190/145

DeAnn, Do you have any idea what your actual requirements stated? I am so worried because I have read of individuals who had to go every month without skipping, and their charts had to be very well documented. Then I hear of others who never had to do the diet even though it was a requirement and were still approved. I have been to my surgeons seminar. I will have my first appointment on October 18th. I waited for this since I knew the diet was required. Shonna

Shonna - What needs to be in the charts? Actually your information about that is much more complete than mine is. If the paragraph you wrote in your original message is direction from BCBSM ... then that's exactly what I've been trying to get my hands on but BCBS won't send it to me. So I'm copying what you've provided and adding it to my file. Although, every single policy is different. BCBS might be the umbrella company with general policies, but each company who contracts with BCBS has the ability to change requirements for their particular contract. That's why some people who have BCBS might say they didn't require any dr. documented diet history, whereas others (like us) require 12 months. Definitely check with your surgeon's office. They should have folks on staff who have dealt with the insurance approval end of things.... but also keep in mind that their information might differ from the exact wording of your insurance policy. I think it's a never ending circle of confusion. Pam