BCBS-TN question
Hello all. I am new here..just hoping for a little direction.
I have BCBS/TN PPO. Our policy states that WLS is not covered unless medically necessary due to morbid obesity. My BMI is 42.3. Any ideas on what else BCBS is going to ask for from me. I have a consult appt with the surgeon, but I'm just curious what they may ask for as far as documentation, etc..
Any input will help.
Thanks!
Mel
Hi Mel,
Welcome to the Tennessee board! Generally a BMI of 40 is required by most insurances. But...if you have comorbidities like diabetes or sleep apnea or heart disease then they usually lower the BMI requirement. The thing about BCBS is that each company can essentially write their own policy. So, what one company's BS pays for another won't. My husband has BCBS of TN but there is an ironclad exclusion written for ALL WLS. I recommend that you call the insurance company and ask. They are pretty good about telling you what you need. Also, have you been to a seminar yet? The people in your surgeon's office will be really good at helping you with the insurance approval and info!
Welcome to the Tennessee board! Generally a BMI of 40 is required by most insurances. But...if you have comorbidities like diabetes or sleep apnea or heart disease then they usually lower the BMI requirement. The thing about BCBS is that each company can essentially write their own policy. So, what one company's BS pays for another won't. My husband has BCBS of TN but there is an ironclad exclusion written for ALL WLS. I recommend that you call the insurance company and ask. They are pretty good about telling you what you need. Also, have you been to a seminar yet? The people in your surgeon's office will be really good at helping you with the insurance approval and info!
Marilyn
Smoky Mountain Obesity and WLS Support Group
1/17 6:30 LeConte Medical Center
Denise M.
on 2/2/09 7:26 am
on 2/2/09 7:26 am
Hi Mel!
I too have BCBS of TN PPO. I'm not sure if the policies vary by employer, though. So what is required on mine may not be 100% the same for yours. Also requirements may vary based on the clinic you are going to. For instance some do not require a pre-op liquid diet while others do. So note that your mileage may vary (YMMV).
The policy I have required me to have a BMI > 40 (morbidly obese) or have a BMI > 35 and co-morbidities, such as diabetes (check!), sleep apnea (check!), PCOS (check!), joint pain (check!), high cholesterol (check!) and so on.
Once you qualify with regards to that, then there are a huge list of things to do. Here are a few of them (for my insurance and my clinic):
--losing 10% of your weight prior to submitting for insurance approval (got there TODAY!). Some BCBS programs make you do a 6 month supervised diet instead.
--having a psychiatric consultation to make sure you know what you are getting into and to confirm you are mentally fit to move forward with the procedure
--attending support group meetings (at least 2; this is a clinic requirement)
--attend multiple dietician appointments
--have pre-op blood work and begin supplement regime (clinic requirement)
--get letter of medical necessity from primary care physician
--get medical clearance/testing
--paperwork . . . they want proof that you've been obese for >5 years, they want to know the programs (diets, medically supervised programs, exercise programs) you have been on in the last 2 years and why you have quit. You need to know your starting and stopping weights, so while you wait for your surgeon's visit, I'd start looking through old calendars or datebooks and coming up with those details. Teeeedious!
With the testing, I was lucky and didn't need anything. The extra tests include things like a sleep study, an upper GI or endoscopy, an EKG and so on. Again, this is defined by your clinic.
They will likely give you a huge packet of specific requirements and forms to complete once you get there, and should be quite happy to review all the info for you. But at least this will give you an idea of some of the things to expect.
It basically took me 4 months to get to the point of being ready to submit to insurance from the day I first met with my surgeon. For some it takes more, for others less.
Good luck with the process and keep us posted!
Denise
I too have BCBS of TN PPO. I'm not sure if the policies vary by employer, though. So what is required on mine may not be 100% the same for yours. Also requirements may vary based on the clinic you are going to. For instance some do not require a pre-op liquid diet while others do. So note that your mileage may vary (YMMV).
The policy I have required me to have a BMI > 40 (morbidly obese) or have a BMI > 35 and co-morbidities, such as diabetes (check!), sleep apnea (check!), PCOS (check!), joint pain (check!), high cholesterol (check!) and so on.
Once you qualify with regards to that, then there are a huge list of things to do. Here are a few of them (for my insurance and my clinic):
--losing 10% of your weight prior to submitting for insurance approval (got there TODAY!). Some BCBS programs make you do a 6 month supervised diet instead.
--having a psychiatric consultation to make sure you know what you are getting into and to confirm you are mentally fit to move forward with the procedure
--attending support group meetings (at least 2; this is a clinic requirement)
--attend multiple dietician appointments
--have pre-op blood work and begin supplement regime (clinic requirement)
--get letter of medical necessity from primary care physician
--get medical clearance/testing
--paperwork . . . they want proof that you've been obese for >5 years, they want to know the programs (diets, medically supervised programs, exercise programs) you have been on in the last 2 years and why you have quit. You need to know your starting and stopping weights, so while you wait for your surgeon's visit, I'd start looking through old calendars or datebooks and coming up with those details. Teeeedious!
With the testing, I was lucky and didn't need anything. The extra tests include things like a sleep study, an upper GI or endoscopy, an EKG and so on. Again, this is defined by your clinic.
They will likely give you a huge packet of specific requirements and forms to complete once you get there, and should be quite happy to review all the info for you. But at least this will give you an idea of some of the things to expect.
It basically took me 4 months to get to the point of being ready to submit to insurance from the day I first met with my surgeon. For some it takes more, for others less.
Good luck with the process and keep us posted!
Denise
Hey Mel
I have BC/BS PPO of Tn thru metro govt and they covered it with some hoops to jump through.........Dr Westmoreland did my vertical sleeve dec 12, 2008 and Wendy (their insurance person) will let you know what you need to do.....good luck and if you have any questions about their program just yell......they are a really good bunch........
WENDY
I have BC/BS PPO of Tn thru metro govt and they covered it with some hoops to jump through.........Dr Westmoreland did my vertical sleeve dec 12, 2008 and Wendy (their insurance person) will let you know what you need to do.....good luck and if you have any questions about their program just yell......they are a really good bunch........
WENDY
The only time you fail is when you fail to try!!!
Welcome Mel! Sorry, I can;t tell you what your insurance covers. The best advice I can give is to contact you plan administrator and ask them.
Now, that was the insurance person talking. Now for the Weight Loss Patient in me...Hop over every hurdle, jump through each hoop, roll with every punch thrown, and then...
BREATHE, and do it again! This will only make you a stronger more determined person!
Hang tight and ask any question you can think of. We're a pretty nice group of people who don't bite, at least I don't!
Now, that was the insurance person talking. Now for the Weight Loss Patient in me...Hop over every hurdle, jump through each hoop, roll with every punch thrown, and then...
BREATHE, and do it again! This will only make you a stronger more determined person!
Hang tight and ask any question you can think of. We're a pretty nice group of people who don't bite, at least I don't!
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