Finally got a copy of my insurance guidelines

After two weeks of calling almost daily to request this, it finally came.  I think they are outrageous.  I had BCBS until this month (employer changed plans).  They are sooo much stricter (I think).  WDYT?  I cried at went to bed.  I feel defeated already.  However, I do have an Ace in the hole so to speak.  I'm a nurse at the same hospital I plan to have surgery at.  I am also a member of the union.  Our union contract states we will have BCBS or equivilant insurance.  We also have a self funded plan and anything done at our hospital is covered 100%.  So I'm going to 1) try to skip insurance approval and/or 2) file a union grievance that our new insurance is not equivilant. ABS Cofinity (formerly PPOM) "Bariatric Surgery Guidelines" -BMI greater than equal to 40 -at least 18 years of age -must receieve treatment at an multidisciplinary approach facility -member agrees to long term behavioral modification support and medical follow up care -documentation in 2 physician suppervised weight loss programs in the last 24 months totally 6 months or longer with one being at least 3 months long -2 comorbidities such as    *hypertension defined at diastolic (bottom number) greater than 100 or systolic (top number) greater than 170     *type II diabetes     *sleep apnea or obese hypoventilation syndrome with 02 sat less than 55     *congestive heart failure with ejection fraction less than/equal to 35% (B**** our seminar the surgeon said he does not do bariatric surgery on people with CHF)    *a genetic form of hyperlipidemia that failed to respond to dietary restriction or medication AND has surgical clearance from PCP completed a psych eval including a MMPI-2 In addition to the above requirements, the following req. must be met for Lap Band or VBG -those members who are at increaded risk of adverse consequences of  a RNY due to the presence of one of the following conditions: -hepatic cirrhosis with elevated LFTS -inflammatory bowel disease (colitis, crohns) -radiation enteritis -abdominal adhesions due to major abdominal surgery with demonstrated complications -poorly controlled systemic disease Information required for submission -documentation of weight loss attempts including WEEKLY or BI-weekly weigh-ins -office records, medication history -PCP letter -psych eval -nut eval is it just me or is this crazy?  When I talked with BCBS last year it was basically BMI >40 or >35 with 2 comorbs, PCP referral and documented physican supervised wt loss attempts

Please don't feel defeated.  You have to stay strong for YOU.  Because you are the only one you have to fight for you.  Tell us which of these requirements that you are failing to meet.  I just want to understand better.

My comorbs are arthritis and urinary incont.  Neither of those are listed... I had a psych eval, but I was given a PPI not an MMPI (even though I mentioned to psychologist that everyone on here had the MMPI, he said he like the PPI better.) I do not have any of the qualifications for the lap band (that is the surgery I have chosen).  I have had two c/s which I consider major abdominal surgery, but I do not have adhesions.   I have a physician supervised wt loss attempt, but I weighed in monthly (as req by BCBS) not weekly (which IMHO is crazy). I still plan to have surgeons office submit, stranger things have happened.  I'm ready to fight for me!  I'm a fiesty German...just ask DH!

Make a checklist and go one by one....pretty soon you will have met all the qualifications and have your surgery.  This process isnt quick and simple.  Takes time, even though we have all dieted our entire lives.  Best of luck and don't give up. Shannon

LOL Shawn on the "german thing" I have a Tech where I work that is a German and OMG there is no stopping / fighting with him either   LOL Hang in there girl ...... keep pushing .... and fighting it will come through for you!!  That's what I'm doing BUT the  waiting is killing me

Hi Shawn.  Actually, the requirements you've listed are pretty common with BCBS.  I also have BCBS and my requirements were the same with the exception of the 6 month diet history.  Think of it this way, 6 months really isn't all that long considering the amount of time it took to put on the excess weight.  You mentioned co-morbids...  Do your feet swell siginficantly when you walk?  Are you winded after walking more than 1 flight of stairs?  Do you have high cholestrol?  Fatty liver disease?  I started my process at a weight of 318 - which meant my BMI was just above 50...however, when my paperwork was submitted, I was at 47 with no major co-morbids.  Aside from my cholestrol being a little high, NOTHING!  Fortunately, I was (and am) very, very healthy.  Needless to say, with the help of my doctor (he's a weightloss specialist and because I had been seeing him for more than 4 months her qualified as my PCP) and the surgeon, my surgery was approved with the first submission.  =)  When the insurance company talks about a multi-disciplinary program (which is really in your best interest) they are really just trying to make sure you will be receiving the best care and have resources (nutrionist, psych., support groups, etc.) available if you need them. Hang in there...don't be depressed.  It's not nearly as bad as it seems...and the time flies!!  If you are required to complete a 6 month program, just remember that the weight you loss during this time really makes the procedure safer for you and "easier" for your surgeon!! If you'd like more information about my experience, please feel free to PM me...I'm more than happy to share my experience.  Best wishes and good luck!!!

the 6 months isn't the problem.  I will restart my supervised diet and I will weigh in every week if I have to.  It's the rest of it... I'm pretty healthy.  It sounds as if they want you to be half dead to get approved.  Why make someone wait until obesity has diminished their health to that point?  I guess if they want to pay for diabetes, heart surgery etc someday I don't see how they are "saving money" by denying me.  sorry to rant but I'm very dissapointed.  I don't think BCBS has as rigerous of guidelines as this...at least not from what I've seen in the past. example: In addition to the above requirements, the following req. must be met for Lap Band or VBG
-those members who are at increaded risk of adverse consequences of  a RNY due to the presence of one of the following conditions:
-hepatic cirrhosis with elevated LFTS
-inflammatory bowel disease (colitis, crohns)
-radiation enteritis
-abdominal adhesions due to major abdominal surgery with demonstrated complications
-poorly controlled systemic disease

I know how horrible the whole insurance process can be.  It's frustrating and angering and defeating.  But you just have to keep fighting and keep pushing.  Have you talked to your surgeon's office about this new information?  They may very well have had dealings with this type of requirements and know exactly how to navigate the list of things you gave. Also talk to your PCP and show him/her this letter you got --- they might have some suggestions on making the process go smoother.  For instance, when you wrote "co-mobidies such as..."  is that the exact wording?  If so, then that's not an exclusive list, just a list of examples.  ANYthing can be a co-mobidity if it's directly related to your weight and your PCP can connect those dots in your letter of support from the PCP.  If your blood pressure is slightly elevated or borderline, get on some low-dose meds... if your cholesterol is slightly elevated, have your PCP prescribe a specific diet or low-dose meds.  Even if you're borderline on some things, get it down in your medical chart.  Doctors are usually happy to help patients out when they know the end result will be beneficial to your health. ALSO --- talk to you employer.  Let them know how unhappy you are with this insurance change and exactly what the change has caused (delay in surgery, additional tests/costs, aggrivation, etc).  They need to know that their decisions to save a few pennies on insurance policies is directly effecting their employees.  I'm the secretary for the Human Resources Director at my office and know that these types of calls are taken very seriously and used when making decisions like these. Good luck, Pam

I can see why you are so upset. I think that is way to much!!! I feel for you. They should look ahead of what might happen and try to prevent it!!! Their rules sound like you have to be on deaths door. I am sorry. Hopefully you can pull some strings. It is just not fair!