Community Blue PPO Plan 12 or Plan 8 coverage questions

Can anyone please tell me what the requirements are for Community Blue PPO (plan 12 or plan 8) to cover gastric bypass (specifically micro-pouch)? I would truly appreciate it.  I tried to get approved through Blue Care Network 2 years ago and was denied because I didn't have 12 months of consecutive diet history (If they checked my history of diet for the past 20 years, how could they deny me ???) --- Anyways, I am interested in trying for this surgery again as I am pushing the 300 lb mark and it is getting harder to do things and I am always tired.  Thanks for any help you can give me, it is truly appreciated, Shari in Irish Hills, Michigan

Blue Care Network (BCN) and Blue Cross/Blue Shield PPO (BCBSM) both use the same critera.   The difference is BCN wants the information up front, BCBSM does what's called a post review - basically the doctor submits the documentation after the surgery has been completed along with the bill.  They then review the documentation and determine payment. 

Hopefully since you tried two years ago you have been keeping documentation to show the 12 months.  If you have not - get to your doctor right away and start this.  You have to have monthly weighins where the doctor talks to you about your weight, diet, exercise, etc.  I went with my doctor for 2 months (using the weigh****cher plan), then went to weigh****chers for 6 months and then finished up with my doctor for the last 4 months.  It was more cost effective for me to go to my doctor.   If work with your doctor, BCN has a really good form on Web-Denis (provider portal for BCN) that your doctor should fill out each time you are there and then keep in your records. 

If you do not have the documentation - don't procrastante - start this week. 

 

Good luck busymom,  I am having the same problem with BCBS the word consecutive in my letter from the doctor to  BCBS is the only thing stopping me from surgery. So what I am doing now is going to the doctor each month to get my time in to please BCBS. Just a short detour to surgery. Hang in there.

I have B/C B/S community blue.. I just had to meet criteria..Being  BMI of over 40 or a BMI over 35 with the co-morbities. I had 38 with 3 co-morbities. I had to meet criteria, but that was it. Did not have to have pre-authorization for my surgery. I had lap RNY on Sept 5th, 07

Shari, i have the 12 plan. I had to do the 12 months dieting, be 40 bmi or 35 with co-morbidites and had to have a psyche ok, wasnt difficult. just have to foll ow their rules, hopefully you can work with your pcp and get the documentation needed and all goes smooth from there. I had no problems, my bariatric surgeons office was great at keeping things moving and getting exactly what bcbs needed. good luck! teri