BCBS AZ six month wait period / guidlines

Hello~ I know with BCBS you have to have six months on a physician supervisded diet, weekly visits with a nutritionist (?), and proof you have attended the gym three times per week.  Does anyony have any advice or can pass along who they used for the weekly nutrionist/dietician visits.  I  had a PCP who I went to for 15 years, but over the last year he has made me feel so bad about my weight, I have stopped going to the doctor at all.   I went to the Dr. Simpson seminar and asked for some referrals of who I could see for they physician supervised diet and the weekly dietician visits, but they said they did not have anyone.  I was really a little surprised.  My feeling was when I left the office, they were more interested in self-pay patients and not really interested in helping patients get approved.  Am I wrong? Thanks ~

I would check to see if its a weekly visit, I can see that costing alot of money, especially if you have to pay the co-pay each time.  I have BCBS of NY and I just had to have monthly documentation, not weekly.   Maybe the gym can provide weekly numbers to your doctor or some kind of documentation.  Get with the trainer at your gym, see if they can keep some records. But, I would double check with your insurance company see if the weekly visits are necessary. Good Luck!

Boy, I understand the frustration!  I went to my seminar in January of this year, met with the surgeon in February and my insurance required six months of doctor directed weight loss, so I met with my PCP who was great about it -- very encouraging.  I thought it was bad I had to do that, but I did not have to meet any of the other requirements you guys refer to (gym and nutritionist).  I did have to go to a nutritionist for an evaluation and I chose one at Good Samaritan Banner hospital and she was recommended by the Bariatric unit at the hospital. Hang in there, I know it can be frustrating.  My insurance did approve me and I was surprised.  Mainly because I got a letter two days after we submitted the request that they did not have enough information to make a determination (sigh) I don't know how much more we could have given them.  I went through all the procedures, jumped through the hoops and did what I could.  It was so frustrating. Anyway, I made it and am scheduled for later this month. Good luck to you

I have BCBS of AZ and have heard nothing about the requirements you mention. But they do require five years of records (I have data from 1996 to the present, but didn't see the doctor in 2003, so they are likely to turn me down). They also require, so I've heard, that I have THREE YEARS of doctor supervised dieting and exercise. I don't have that either, though I've discussed diet and exercise with doctors since 1996, apparantly they don't write down that we discussed that in their notes.  My doctor's office seem to be very empathetic about helping me try to get approval. They've bent over backwards to beef up my application even while it is in the primary approval process (I haven't been turned down yet)... they've even collated information going back 12 years, fetched data from odd places, and listened to me calling them up daily. I'm on a first name basis with all three of the wonderful ladies in the office there (Eleanor, Stevie, and Carmen) and they are just great.  As a teacher married to another teacher, we are just not rich enough to do the self-pay thing. I'll just diet as hard as I can, and in two years, when I've gone from a BMI of 55 to a BMI of 40, they'll have to pay for the surgery anyway! (as long as they don't exclude it in the next two and a half years!)  I'm pessimistic at the moment about approval, but who knows, perhaps they'll approve me. With the medicines I'm on they'll probably spend twice the cost of surgery in the next two years just paying for my prescriptions. Seems silly to do that when the surgery would eliminate my prescriptions literally overnight. (their part of just ONE of my many prescriptions is $4000/year).  We'll see what they say!

Thank you for the responses.   Yes, Nicole, I am going up to the gym  next week and see if they can provide me  print out at the end of six months with the attendance.  Thanks! Beth, good luck and congrats on your upcoming surgery! Lithia , I would definitely call BCBS myself Monday.  I have been waiting on them for almost two years to start covering the Lap-Band.  They have always covered the RNY, but I never was told about the 5 years of medical records (I think that is BCBS of CA) nor about the three years of supervised dieting.  I would definitely call myself and get it from the horse's mouth.  You may not have to wait that long!  And you know about the $1000 access fee on top of your deductable, right?  I have a $5000 deductable plus the $1000 access fee.  I know about the self-pay thing.  It is great for people who can afford it, I just cannot at this phase in my life add that kind of debt.  I am just waiting for Dr. Blackstone's office to actually return my calls so I can have my first appointment there.  Then I can make a decision on a surgoen.  I just want to get started on this six month thing and get the ball rolling.  I could bite the bullet and return to my PCP, but I don't know if it would be like pullling teeth getting the documentation out of him.  I was lucky he scribbled an okay for surgery on a prescription pad 18 months ago when I filled out my original paperwork before finding out BCBS did not cover the band at that time.  That is one plus for Dr. Blackstone's office in my book, they do the supervised diet right there in their off and have the documentation in front of them.  ~ sigh ~

Sorry, one more thing...  Lithia, also with BCBS AZ, if you show a 5 pound weight gain in the six months, they will automatically turn you down. 

I think that the most difficult part of talking about insurance companies is that there is more to it than just the insurance company, there is also the existing PLAN that muddies things up. When I called my insurance company, they told me (from the horses' mouth) that they use another company (American Health Group) that does the pre-certification for them. So I have to be approved by American Health Group (AHG) whose qualifications are a lot more strict/stringent than any that BCBS. Then I called AHG (this is before my first seminar even) and they sent me an official document that listed out the requirements I mentioned. The requirements were:  1. have a BMI > 40 for the previous five consecutive years. I've been SMO for 22 years, so didn't think I would have an issue with this one, but I didn't see the regular doc during 2003. I did go to the emergency room twice that year. Once to an urgent care place that no longer exists, and am not sure with my broken foot if they actually weighed me, second time to a brand new hospital here in the West Valley, and am not sure THEY weighed me but I've sent for those records now. The insurance company has medical records from 1996 - 1998, 2001 - Present, excluding 2003 when I didn't see a doctor. This means they might have to wait until 2008 and I get weighed again before they will consider approving me.  2. Must have been under a physician's care and treatement during the previous 3 years for problems related to the diagnosis of MO and its complications as evidenced by submitted notes and tests. Again, they have this documentation.  3. Patient must show documented history of "failed" weight loss efforts or programs over the past three years as monitored by their physician. I talk with every doctor about what I'm doing to lose weight. Hubby and I bought a house with a swimming pool so that I could exercise daily from March through October (and I've done that too). I've discussed diet with my doctors, and each time I have seen them, and gotten suggestions, and tried new things each time I've visited with them. Sadly, it appears that none of this is actually written down  in my records.  4. Psychiatric Evaluation (MMPI) within the last 12 months recommending approval for bariatric surgery I've done this, passed with flying colors. had to pay for it myself, BCBS said they would pay their half if I get approved for surgery. 5. Letter of medical necessity from two independant physicians not in association with the surgeon or one another. I saw my old doctor and new one and got letters from both. My old doctor's office was condescending and I really hated them, which is probably why I never went to see the doctor in 2003.  6. Be 18 years of age (I wish I was that young!) 7. Have recent labs (I have) ------------------- I was never told about any sort of Access fee. On my plan I have to pay $50 to the surgeon, $50 to the anaesthesiologist, $100 to the hospital, and $15 copay for every doctor visit while hospitalized and for every simple test and $50 for every complicated and expensive (more than $500) diagnostic test that is performed. I don't have a deductible. Again, these are all differences in different plans. I was not told that I had to lose any weight pre-op by the surgeon or the insurance company (but that might be something they only tell me once I'm approved), though I know that the surgeon told me he would have me on a two week liquid diet before and two week liquid after surgery, followed by four weeks of purees. My personal goal is to lose 10% of my weight at the time of consultation by January 1st. (I weighed 332 and lost 11 in three weeks, now I have only to lose 22 more lbs by January first to be below 300 lbs. I'm doing this for me, to prove to myself that I can take this surgery seriously.  Thank you for your response to my post. Wouldn't it be easier if there was just one set of guidelines and if anyone could make those guidelines, they could have this surgery?

You are right, I keeping forgetting the different provision in the different plans within an insurance company.  I have an individual policy as I am self employed, thus the $1000 access fee is for the individual policy holders.... :-)

IF I had to pay $1000 to get guaranteed approval, I would. :)  Good luck to you.

After reading about all the issues with other insurance I am so thankful that I have UHC choice ..If I get approved my out of pocket is 0 for the surgery just 10.00 co pay to go to Dr ...now im just waiting ..its all up to the insurance now ..   101 #   36.5 BMI ..lots of issues with that !!