EMPIRE - BCBS - PPO - NY

Hey everyone I was just curious if anyone else has this insurance. I have called them repeatedly trying to find out what their requirements are for WLS. The only thing I keep getting from them is to have my doctor submit the paperwork for pre-certification and a letter of medical necessity. I keep asking about the diet and they just keep saying pre-cert and medical necessity letter. blah blah blah. the reason i am so confused and scared is because a couple other ladies i work with have had it done. One no diet was asked and the other it was demanded. I dont understand we all have the same plan and benefits???has anyone had any other situations like this? I have diet history just not a cosecutive 6 months...... P.S. I am a frequent lurker and love everyones posts......thanks in advance

Hi Kenna BC/BS requires a 6 month supervised diet and it must be included in your letter of medical necessity. They are pretty good with approving you right away as long as they have everything they need. That letter of medical necessity goes to your Surgeons office and they submit it to the insurance company with all your required tests. Your surgeons office should be handling your insurance issues. NOT YOU. Honestly, my doc knew my diet struggles and he personally wrote something up for me without having to go through another 6 month dieting. He felt is was a waste of time and not necessary. So he made up the 6 month plan and they accepted it. Let me know if there is anything lse I can help you with. Where is your surgery and who is doing it? Marie

Thanks Marie, I am using Dr. Scott with the SSM DePaul Weight Loss Center in Missouri. I appreciate your info. I will see what I can get out of my pcp as far as 6 months.....he is quite the stickler so I am sure he will say no......I went 4 months then off 2 and back 3 more........death in family and went out of town......so thats why not consecutive. Surgeons office doesnt really want to submit it without the consecutive 6 month diet either thats why I was trying to get in touch with BCBS to get a lil more info.......it is all starting to get sooooooooo overwhelming.......thanks for all

I strongly recommend caution in asking a provider or posting about a provider to/who perform(ed) insurance fraud. Take Care, Jamie Ellis RN MS NPP 100cm proximal Lap RNY 10/9/02 Dr. Singh Albany, NY 320(preop)/163 (lowest)/174 (current) 5'9'' (lost 45# before surgery) Plastics 6/9/04 & 11/11/2005 Dr. King www.albanyplasticsurgeons.com http://www.obesityhelp.com/member/jamiecatlady5/ "Being happy doesn't mean everything's perfect, it just means you've decided to see beyond the imperfections!"

My insurance provider did not perform fraud. I had already had a previous 6 or more months in of a supervised diet and he didn't feel it was necessary for me to do it again. Thats why he did it. Marie

Marie: Thank you for clarifying, as you wrote above it was not clear: Honestly, my doc knew my diet struggles and he personally wrote something up for me without having to go through another 6 month dieting. He felt is was a waste of time and not necessary. So he made up the 6 month plan and they accepted it. How I understood it you did NOT meet the insurers requirements and it was 'made up/he didn't feel you needed to meet criteria' or you were 'promoting others do this' that would be insurance fraud on your/providers part to get you a service w/o meeting criteria set (whether that criteria is good/bad is not the issue). http://www.insurancefraud.org/fraud_backgrounder_set.html Soft Fraud. Normally honest people often tell "little white lies" to their insurance company. Many people think it's just harmless fudging. But soft fraud is a crime, and raises everyone's insurance costs. ( I am not debating if a 6mo medically supervised diet is a good or bad thing), I just caution people who can be quite impressionable here and take advice openly, getting the full meaning is hard w/ posts I realize and my concern is no one knows who is on here (your insurance company etc) as it is a public domain, I have seen people post to others to get Plastic surgery to alter there appearance (use nair, brillo pads) etc to get a TT covered, and although I think insureres should cover TT for WLsers for me I feel committing fraud is not the way to get it done. My intent was to avoid that and thank you again for clarifying! Take Care, Jamie Ellis RN MS NPP 100cm proximal Lap RNY 10/9/02 Dr. Singh Albany, NY 320(preop)/163 (lowest)/174 (current) 5'9'' (lost 45# before surgery) Plastics 6/9/04 & 11/11/2005 Dr. King www.albanyplasticsurgeons.com http://www.obesityhelp.com/member/jamiecatlady5/ "Being happy doesn't mean everything's perfect, it just means you've decided to see beyond the imperfections!"

I have this ins and got approved in about 2 weeks. My Dr. has worked with them many times and said they are very good, as long as your Surgean puts the paper work together right, you shouldn't have a problem. I don't know if the insurance or your Dr. is the one requesting the diet. My primary care Dr has worked w/ me over the years. while i tried a ton of diets. I put together a list of everything I ever tried in the last 5 yrs. (Boy was I surprised at how long it was). She confirmed, My surgean had me go for all my tests, also a letter from a shrink. and it was ok'd. I think empire requires a bmi over 40, or 100lbs overweight. If you don't meet those then your dr. needs to show if medically necessary. Most people I know of with empire don't have any problem. Good Luck!!!!

thanks for the reply........by BMI is 43 and I have GERD and Sleep Apnea.....I am hoping those 2 will out weight the consecutive 6 month diet.......time will tell......thanks again for replying

I have Empire BCBS PPO and had my surgery in September. They did NOT require a 6 month diet; just a letter of necessity....and I was approved in 3 days! It was a pleasure dealing with them; they even covered the "at-home" nurses that came in the week following my surgery. Best of luck! -Karen

I have BCBS of CNY. I realize it is probably not the same as the ppo but I had no problems. They required a 5% weight loss and lots of pre-op testing but no 6 month history. Once the DR submitted the paperwork, I was approved in only a few days. Good luck! Kier