Anyone approved by Premera BC Heritage Plus?

I just started the process. I decided to have the surgery on my own because I didn't have a PCP, so I don't have a "physcians referral letter". My BM is 47 and I have a handful of co-morbidities (insulin resistance, hyperlipidemia, and GERD) and suspect a few more (apnea, neuropathy). 've met with my surgeon and (new) PCP and have scheduled all the other things required by my surgeon (nutritional assessment, sleep study and psych eval). I've had my abdominal ultrasound (found gallstones) and EGD (found hiatal hernia), and should be getting my blood test results back sometime next week. I'm really getting frustrated with Premera. According to the policy you are eligible for WLS if you have: 1) failed previous diet and exercise attempts  (define "failed"!!?) 2) BMI of 40+, or BMI of 35 with co-morbidities 3) the WLS procedure is an approved medical procedure for the treatment of obesity (i.e. NIH recognizes it - like gastric bypass) But then they go on to say a Benefits Advisory is recommended for authorization. So when I called about what was required for the Benefits Advisory, they told me they'd fax the info to the surgeon. My surgeon expects the patient to do the legwork with the insurance, so I asked them what "supporting documentation" was required from the surgeon when he submitted the request for Benefit Advisory (so that I could make sure he had everything they required the first time around) and they made some vague ascertain that everything was on the website -- which it's not! So, my question is: has anyone gone through the approval process with (Microsoft) Premera BC and can you shed some light on what documentation they required?  I've heard horror stories about insurance companies requiring 5+ years of documented weight history (like medical charts), previous physician supervised weightloss attempts, 6 mos. supervised program from the start of the pre-op process, etc.  I'm willing to do the work, but if the insurance process is just going to be full of obstaclesand excuses for delaying the surgery (like not telling us everything they require and then sending the request back several times for more information),I might just have to sell my stocks or cash in my 401k and self-pay instead. Thanks, Jennine

Jennine, I personally was not able to go through my insurance (I also have premera but a different plan) because they absolutely do not cover it.   Not to come down on your surgeon...but most surgeons are willing to do the leg work with paperwork for insurance.  Not only will they know better what the requirements are but they will be able to use wording and such that insurance companies understand and respond to.  I know my surgeon's office does TONS of legwork for their patients.  Anyway, that's the first thing. The second thing would be to perhaps just send in the request for a preapproval with documentation showing your BMI and comobidities and I've read many people who said their stuff went right through with no trouble when using Microsoft's insurance plan.  If they deny it then you can start jumping through hoops but it's always worth it to try the easy approach first.  Like I said, most people I know that have had surgery and work at MS haven't had any issue with approval. Hope that helps a little. Corinna Q

Hi Jennine I have Aetna insurance.  and I too had questions that were not answered via phone calls or seemingly evasive.  See if  Premera BC  has any "clinical bulletins" posted on line which has requirements detailed and includes the 5 years of documented weight history etc.  which by the way for me was "a date of office visit, my weight on that day of visit and a documented ICD9 code for obesity."   The insurance company didn't explain that, my surgeon's office manager did.  82 pages of documentation were faxed to my contact person via the surgeons office and she was a bit "upset" that she received "so much" but guess what, if they refuse to specify what it is they're looking for, then send more rather than less.   My information was submitted on a Thursday and the following Tuesday I had a verbal approval. Don't despair.  I'm guessing Microsoft is self-insured so see if someone in your benefits office can get you the information you want in writing, if Premera BC doesn't have it on line.  For Aetna, it's clinical bulletin #157 and it's buried in their web site so keep hunting. Good luck Nona

I also am from Washington and have Premera but it is an exclusion. Microsoft absolutely covers it. Do not worry, just make sure you call them and get the info from Premera. If they give you a hard time, let Microsoft know, they have been through this before and are pretty supportive. I also agree about the surgery thing. I have Dr. Oh and his office staff is FANTASTIC!!! They have been through it enough and walk you through the insuracnce process. Good Luck!!

Thanks for the support. I'll check for clinical bulletins on the website . I'll probably sic my hubby on the MS Benefits team for answers since he's the one who's still an employee and the primary now - besides he gets scary-angry so much better than I do :) My surgeon does have someone to help with INS filing but not the major legwork. I can understand... having a team of people to handle all these different companies for each patient would seriously drive up his overhead costs (which then get passed on to the patients in higher fees). I don't mind doing the work, just dealing with the evasive INS personnel (I swear they're probably trained under torture and truth serum not to be helpful). I know I'm being a spz... but I had a very, very bad expereince with INS on a surgery when I was younger and it's made me gun shy. Thanks for putting up with me.