BCN and BMI over 50 ????

Hello, I was just on the blue care network website and I saw that if your BMI is over 50, you don't have to have the 6 months documented diet history ...... has anyone had this done recently, is this correct?  It used to be 12 months diet history and they cut that in 1/2.  So do you just call a Bariatric Surgeon if your BMI is over 50 and tell them that you want the surgery and they set everything up????  Please respond if you know something about  this.  I would like to have the surgery before summer is over if possible.   Thank you so much, Shari 

Absolutely true!  Like Blue Cross Blue Shield, BCN will waive the six month medically-supervised diet for patients with BMI 50 or greater.  If you have a co-mobidity, like diabetes, this will almost assure approval, providing other test show you are a safe candidate for surgery.  My surgeon, Dr. Mark Pleatman, wasn't sure about it, so I called BCN and they verified it for me.  In fact, they sent me a list of all bariatric procedures with codes that are covered with PCP approval.  At the end, there is a list of requirements.  I'm with you, Shari, I'm hoping for VSG surgery before the end of July.  Tomorrow I meet my surgeon for the first time at an information session.  Next, the consultation.  I'm excited!  --- Alma Rene

Hello Alma and thanks for the reply.  So it's not enough just to have the BMI over 50, you have to have at least one co-morbidity along with it?  I'm kinda new at this so I'm not sure how the procedure codes help.  Can you explain?  My current BMI is 49.5 .... It would be alot easier to gain 5 lbs and put my BMI over 50 than it would be to wait another 6 months. -- I appreciate any help you can give me.  I am interested in having Dr. Wood at Harper Hospital do my surgery.  He and Dr. Sapala are the ones that invented and patented the micro pouch so I feel pretty confident with him.  My best friend had the surgery and he was her Dr. too and she loved him.  Again, I appreciate your time and help. Have a wonderful day !! Shari

Shari, I wish I could be more helpful, but I'm just learning as I go, too.  I attended an information seminar last night where I met Dr. Pleatman for the first time.  He seemed convinced that BCN will NOT approve Bariatric surgery.  I told him they sent me a list of requirements and codes for approved surgeries and I meet all these requirements.  He said, "They say that, but then I'll send it in, and they'll deny it."  Plus he wants $1,500 out of pocket besides what insurance will pay BEFORE he'll even do the surgery.   I don't have that kind of extra money right now.  Beaumont only wanted $600.  Too bad they are not yet a Bariatric Center for Excellence that BCN will approve and no surgeon there will do the VSG.   I'm going to call Harper Hospital today and ask about Dr. Wood and Dr. Sapala.  I want the Vertical Sleeve.  I know there is one other surgeon who works out of Harper Hospital who will do it.  If he isn't asking for such a large sum of money out of pocket, I'll choose him to do my surgery.  I still want it, but I'm a bit discouraged now.  You might as well know that putting on weight will not help you get approved because---and here is what had everyone at the seminar glaring at each other in disbelief---you will be asked to lose weight before the surgery!  I already knew about the 2 week liquid diet pre-op to soften your liver, but Pleatman expects his patients to lose 10% of all the weight they want to lose.  If you have 200 pounds to lose, he'll expect you to take off 20 pounds the next visit or he'll cancel your surgery.   I plan to follow up with my PCP for the medical and psyche evaluation BCN requires.  I'm too curious now to see if BCN really will approve my surgery.  I'll keep you posted.  Meanwhile, please tell me if you were asked to pay any additional out of pocket costs.  Oh, and no, you don't have to have a co-morbidity like diabetes, but any complications of obesity certainly helps assure approval.   ---Alma Rene

Hello Alma, I attended one of Dr. Woods seminars with my best friend in 2004 and it was very helpful ... I knew most of the stuff before I went because my best friend educated me as we went along, but we had different insurances .... she had BC Community Blue PPO and was approved and had her surgery within 4 months.  I'm still waiting ----------  I don't understand why Dr. Pleatman wanted cash out of pocket before the surgery.  ---- Also, Dr. Wood never said anything about losing weight before surgery or not getting it although I have heard that some doctors if the BMI is too high, will request this.  If you could lose 30 lbs on your own, then why would we need the surgery ????????????? Dr. Woods works right out of Harper Hospital ... have you called him yet?  Please do, and let me know what they say.  I am pretty sure Harper Hospital has their own Bariatric Unit because that is where he works out of and that is where my best friend had hers done also.  You won't be disappointed with Dr. Wood, if you read anybody's profile that had him for a surgeon, they  will all say that he is very warm and caring and doesn't make you feel disgusting or obese about yourself. I already knew about the 2 week pre-op liquid diet also.  I have not gone to the doctors about my weight but maybe 2 times in the past couple of years because I don't focus on myself.  I have 3 boys, 18, 12, 10 and along with my husband and my job (CNA), that is my focus.  I don't have the time right now for myself ------- I know if I have the surgery there will be no choice and I am ready for that because my kids and husband are the main reason I want this surgery, I want to be healthy, I want to live to see my grandkids, I want to be able to retire with my husband and look back at all the time we have shared together, if I continue like I am, I'm sure I'll have either a stroke or heart attack ....... both run in my family along with diabetes and cancer .... Lucky Me, huh? Please keep in touch, I am very curious to know what Dr. Woods office will say to you. Good luck and don't let anyone discourage you, you are the one that has to live in your body and no one else !!!! Shari

Good news, Shari!  I did call Dr. Wood's office. He will do the Sleeve.  It's just not advertised on the website yet.  The woman I spoke to took down my insurance information, stats on my ht and wt, health facts, my PCP's name and phone number.  She told me the kind of test results and information required to get the surgery approved---psyche evaluation, letter of support from my PCP, an EGD (esophagogastroduodenoscopy-- diagnostic endoscopic procedure that visualizes the upper part of the gastroentestinal tract up to the duodenum) by a gastroenterologist, etc.  What a world of difference!  She started the process toward preparing me for the surgery.  As long as BCN will approve me, it's a foregone conclusion that I'll have VSG!  She did say that I may not be able to get an appointment with Dr. Wood before mid or late July, but that's okay. It gives me time to get the tests done so I can deliver everything required on the day of my consult.  I told her about Dr. Pleatman wanting $1500 up front, and she said there is no out-of-pocket cost other than my copays and deductibles from my insurance, if I have any.  That's encouraging!  I'm hoping to be sleeved before the end of August. I already called my PCP's office and they gave me the name of two possible gastroenterologists to call for an appointment, just in case one has no available appointments in the near future.  They also suggested I call BCN for a referral to a psychologist for the evaluation, just to make absolutely sure that the results will be accepted for bariatric surgery by that particular provider.  My brother even volunteered to drive me and stay with me the day of the EGD test.  Everything is in place and moving full speed ahead!  I'll keep you posted.  I will be attending a group support session at Dr. Wood's office on Wednesday, June 25.   

Hello Alma, I am so happy for you ... I thought it sounded odd that the doctor wanted out-of-pocket money ... makes you wonder if he just pockets that money ... pretty bad, huh???    You will not be disappointed with Dr. Wood.   Can I ask you why you chose the sleeve versus the micro pouch or other procedure ... just curious. -- It sounds like the wheels are rolling for you.  Please keep me posted ... it would be exciting to know that some small amount of information that  I provided you with would help you get to your surgery goal ... YIPEE !!  I am excited for you now.  What city are you going to for the support session with Dr. Wood's office?  -- I don't remember needing an EGD before ... is this something new or only required for the sleeve?  I am just getting over strep throat and my blood work they took the morning I went in for my strep appointment came back that my WBC's are elevated and my glucose is high.  I have to go back for new  bloodwork in 10 days after the antibiotic is gone.  At that point, if that test result comes back with high glucose also, maybe I will see if I can start the process then.  I am afraid if I start the process now, with my BMI only being 49 and not yet 50, that they will reject me because I don't really suffer from co-morbidities (on paperwork that is). Well, gotta head to work, hope to hear more from you later. Take care and have a wonderful day ... oh yeah, if you want to, you can email me direct at [email protected] -- Did I ask you what city you lived in.   I live in Clinton, just west of Saline near Irish Hills.

http://ereferrals.bcbsm.com/docs/BCN_referral_chart_07.pdf

Hello Melissa, Thanks for the link.  I just printed that page before I posted what I did.  I wanted to make sure the insurance company didn't demand more once you applied and if you had to have a co-morbidity with the BMI of over 50.  Have a wonderful Summer, Shari

I have BCN and that is correct.  This change was effective in January I think, I didn't find out about this until I was looking into wls.  I started my process by calling MMPC (Dr. Baker's office)in Grand Rapids and was scheduled for the informational meeting.  You will want to call BCN to obtain the list of programs and hospitals that are approved by them.  My surgeon's office helped me through the rest of the process.  Their office staff was a great help with insurance questions.  Good luck and I hope this information helps.