BCBS-NE

rness
on 9/10/08 12:49 am - Champlin, MN

I posted this on the general forum but thought I would try hear. I have BCBS-NE, but I live in MN.
This is what my policy states for WLS. Anyone else w BCBS NE. Im just curious how your approval went. Thanks!

The following surgical procedures are scientifically valid in the treatment of morbid obesity:
* Roux en Y Gastric bypass
* Gastric stapling
* Biliopancreatic diversion with duodenal switch
* Laparoscopic or open gastric banding (e.g., Lap-Band
* Loop gastric bypass

Laparoscopic methods to perform the above procedures are scientifically validated.

All other surgical procedures, including biliopancreatic diversion without duodenal switch, are investigative.

POLICY GUIDELINES:

The screening criteria listed below should be utilized before any surgery would be considered medically necessary:

MEDICAL POLICY MANUAL

1. The patient must have morbid obesity (BMI of >/= 40 kg/meter squared) or a BMI of 35- 40 kg/meter squared plus significant comorbidity.

2. The duration of obesity must have exceeded five years.

3. No identified treatable medical cause (i.e., endocrinologic).

4. Age >/= to 16 years of age.

YdnicKay
on 9/10/08 9:29 am - NE

Lap Band on 11/25/08

I have two different BCBS polices. One through my husbands work, which at this time does not allow WLS. My BCBS policy allows WLS as long as it is medically needed. I filed approval request through both policies and mine okayed it in 10 days and my husbands said no as of July. But they did mention there was a chance they would begin approving WLS in September. I haven't check yet. It looks like you shouldn't have any trouble as long as you fall in the guide lines in your policy. I hope this helps. Cindy

rness
on 9/11/08 12:16 am - Champlin, MN

RNY on 06/08/09

Thanks,
I am however, getting conflict information every time I call BCBS and ask a question. The latest is now Im being told that the surgery is covered however, the treatment is not. Which I really dont understand. I guess the preop stuff is, but the follow up appts are not.

My husband was like "Oh well, if its important to you, we will make it work".
Thank God, because I know its going to be very expensive.

blueeyesblinkin
on 9/22/08 5:14 pm - BFE, NE

RNY on 04/24/08

I have BC/BS from Nebraska as well(from nebraska). Alot of it depends on the employer as well. I had no problem getting approval: BMI at 54, no co-morbidities no pre-op 6 month diet. However, when I called to find out if my insurance would pay for the surgery they wouldn't tell me until the info from my surgeon was submitted. It took about a month after the info was submitted before I knew.

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