Info about BCBS M Weight Loss Criteria and Guidelines received from my doctors office

Hi everyone!  I stopped by my surgeons office today to talk with the insurance coordinator and she was really helpful.  She said they just got the updated criteria from BCBSM recently.  She gave me a copy.


I am going to post what I was given.  Again, confirm this for yourself in case I am in error.

BCBSM Provider Publications and Resources

Procedure: Gastric Surgery for Morbid Obesity

Criteria:

1.  The patient has a body mass index greater than 40, or a BMI of greater than 35 with comorbid conditions (such as degenerative joint disease, hypertension, hyperlipidemia, coronary artery disease, presence of other atherosclerotic diseases, type 2 diabetes mellitus, sleep apnea, or congestive heart failure).

2.  BCBS no longer has age-dependent criteria for bariatric surgery for adults.  Risks and benefits of the planned surgery, including those related to the patient's age, should be documented in the clinical record.

3.  An M.D. or D.O. must evaluate the patient.  The physician should document, in the medical record, the failure of nonsurgical dietary weight loss prior to recommending bariatric surgery.  This documentation should include a thorough dietary history including the patient's periodic weights, description of previous dietary attempts, physical exercise, behavioral therapy, counseling and pharmacotherapy.

4.  The surgeon should document that the patient understands the benefits and risks of the available surgical and nonsurgical management strategies.  This documentation also must include an informed decision to proceed with bariatric surgery with an understanding of the surgical risk and the commitment to medical management thereafter.

5.  A contracted mental health professional must perform a psycchological evaluation as a presurgical assessment to establish the patient's emotional stability, his or her ability to comprehend surgery risks and to give informed consent, as well as the ability to cope with expected postsurgical lifestyle changes and limitations.  This consultation may include one unit of psychological testing for purposes of personality assessment (e.g., the MMPI-2 or the adolescent version, the MMPI-A).  The psychological evaluation must be signed.

6.  The physician should arrange follow up of individuals who have had gastric surgery for any long-term complications.

7.  If a prior bariatric surgery is being revised, the medical recored should include:
   - Date and type of previous procedure
   - The factors that precipitated failure
   - Any complications from the previous procedure that necessitate the takedown

If the indication for the revision is a failure of the patient to lose a desired amount of weight, then the patient must meet all of the initial preoperative criteria.

8.  Sleeve gastrectomy is payable only when provided as a first stage of a planned multi-staged bypass pricedure for supre obese (BMI >50 kg/m2), high-risk patients.  It remains investigational and not payable as a primary, single bariatric procedure for patients with BMI < 50.

9.  At this time, BCBSM considers the following procedures investigational, not medically necessary, etc:

loop gastric bypass gastroplasty - also known as mini-gastric bypass

stomach stapling



BARIATRIC SURGERY GUIDELINES OUTLINED:

BCBSM does not pre-authorize bariatric surgery procedures.  As with any other covered medical service, we expect the physician to document in the clinical record the indications for and medical appropriateness of the procedure.

For bariatric surgical procedures this documentation should include:

1.  Morbid obesity with a body mass index of 40.0 or more.

2.  Morbid obesity with a BMI between 35.0 and 39.9 with significant obesity related comorbid conditons.

3.  A thorough dietary history.

4.  Documentation that the patient understands the pros and cons of various approaches to the contuinued management of his or her condition including continued medical weight loss and has made an informed decision to pursue bariatric surgery.

5.  A psychological asssessment documenting psychological fitness and readiness to undertake this surgery.

6.  Documentation of the patient's commitment to participate in the post surgical management program of the bariatric surgery program.

Sleeve gastrecomy: Sleeve gastrecomy is payable as the first stage of a multi-staged surgical approach to the treatment of obesity for patients with a BMI over 49.9.  We continue to consider this procedure experimental in other patients or when it is provided as a definitive surgical treatment for obesity.

Blue Care Network also provides some members coverage for bariatric surgery.  Look for information about their benefit in an upcoming issue of Network News.


Again I am only posting what was given to me.  I would make sure you contact your insurance company or doctors office to confirm the requirements and criteria for your weight loss surgery.

Hope this helps.

I’ll have to call them and see but it reads like now for SMO patients with BMI over 50, we have to do the 6 months of dieting history now where we didn’t have to before…

 

So I’ll have to call them when they open up today to clarify that.

 

If so, it pushes my earliest surgery date back by about another 3-4 months :( Not good news for me.

NM, I called BCBS and I read the post wrong. 6 months dieting is waived for lower BMIs now, not just >50.

I hear ya about getting a surgery date.  Today's first appt with the surgeon, next an appt with another doc for medical clearance, then another with the surgeon to schedule a surgery date and then probably will have to wait a couple of months for the surgery.  But, it's one step at a time, patience, patience, patience.
Jan

Now Stimpy, aren't you glad you were persistant?

Jan

I am definately thankful for the staff at my surgeons office.  They have been very helpful.  I am glad I stopped in yesterday to talk with them again.  No more worries for me about insurance.  :)

Glad to hear BCBSM hasnt made too many drastic changes.

This is great information.  Thank you for taking the time to do this.  I think whomever moderates this forum needs to make this post sticky.

Anytime, glad to be of help.