Got my letter of criteria for weight loss surgery and here's what it says...

I must note that it appears to be hand typed on BCBSM letterhead instead an already put together handout like I had expected to be given. It mentions nothing about a BMI greater than 50. Here is what it says: Surgical procedures for severe obesity are considered established treatment options when all od the following criteria are met: The patient has a body mass index greater than 40 or greater than 35 with comorbid conditions. The patient is between ages 18 and 60. A medical doctor or doctor of osteopathy has documented failed medical management, including a structured professionally or physician-supervised weight-loss program for a minimum of six consecutive months within the last four years prior to the recommendation for weight loss surgery. There is a documentation that the primary care physician and the patient have a good understanding of the risks involved and reasonable expectations that the patient will be compliant with all post -surgical requirements. A contracted mental health professional has performed a psychological evaluation to establish the patient's emotional stability and ability to comply with post-surgical limitations. The information in this letter is intended to provide you with basic benefit information and criteria guidelines for weight loss surgery. We will base our services on whether the criteria are met and upon our review of the procedures and diagnosis codes submitted by the providor or providors rendering the services. To anyone who actually took the time to read through all of that, THANK YOU!!!!! Does this mean that I definately have to do the 6 month diet first? If so, then I really need to get started. Is there something that I should do first to make absolutely sure that it's not waived because of my BMI of 57?

Have you done Jenny Craig, WW, or any other diet that has monitered your weight over the past 2 years that would equal 6 months?  They generally accept this period of time.  

Hi, Do you have BCBSM PPO?  Thats what I have.  My sister and I had surgery the same day.  we both have BCBSM PPO.  My BMI was 40 and hers was 58.  I had to have a 6 month documented diet regimine.  She did not.  What they explained to us, is, that if your BMI is greater than 50 you do not have to have documented weight loss attempts.  This just changed at the beginning of this year.  It used to be 12 months of documented weight loss.  I was so happy when they changed it.  Hope this helps you.

Hi! What you wrote is what the BCBSM PPO customer service rep read to me (I called the number on the back of my card.)  I asked "What if your BMI is greater than 50?"  She said "With a BMI over 50, then you do not need the 6 months medically supervised weightloss attempt. You are approved based on the BMI.  But you still need all the rest."  I don't know if it is because ours is GM or what.  It just doesn't make any sense that they will not state anything different for BMIs greater than 50. Good luck!  I wish I could be more help. Gwen

Yes, it is BCBSM PPO and Gwen you said GM, my husband's employer is Ford. Ok, so there is a number on the letter to call for further questions. I will be calling it first thing Monday morning to ask them specifically about a BMI of greater than 50.  Will I need to ask them to mail me information about this as well? I also have another question, why is it that I gave all of my height weight and insurance information to the guy at the surgeon's office and he called me back and told me that I have to do 12 month diet first. Shouldn't this guy be able to do a better job dealing with the insurance company than I can?

Robyn - The guy are the surgeon's office is probably working off old information from BCBS.  The requirements just changed on January 1st, so he probably hasn't updated his cheat sheet.  Once you get the information from BCBS about your requirements, give a copy of everything to the surgeon's office as well.  Although, he can call and get this information too if he just took the effort. You don't necessarily need to have the requirements in writing - it's a good idea to have it in hand, but not absolutely necessary.  So whatever makes you feel more comfortable.  Good luck Pam