Who do I believe? (BCBS question)

I have a question about the "12-month doctor supervised diet history" that is required by BCBS. I called BCBS and spoke to a customer service representative and asked specifically if I need to have 12 montly visits within a 1 year time period where I check in with my doctor every month regarding my diet.  OR, is 3 visits spaced out through a 12-month period with discussions about my diet and exercise plan sufficient.  He told me specifically that the 3 visits within 12 months would fulfill the requirement for surgery. However... When I call my surgeon's office to tell them all my requirements were complete and I was ready to have them submit my paperwork to BCBS for approval, they said that BCBS requires 12 monthly visits within a year.  That the 3 visits would not be enough.   So who do I believe?  If the surgeon's office thinks I won't be approved, should I have them submit the paperwork anyway and risk a denial?   Thanks for help, Pam

I don't know which BCBS  you have, but mine was very specific about the fact that you could not skip a month.  Mine was a 6-month supervised diet and you HAD to be seen monthly and it couldn't just be a documented weight.  They required that the physician document the weight and also what diet and exercise program the person was on.   Now...I wasn't told this by anyone at the insurance company when I called.  I learned this might be the case on this board by reading about people who'd been denied because they missed one visit.  You might be able to get away with it if you were weighed somewhere (like gym or WW or something) and can provide documentation of your weights during the months you did not see the physician, but that might not work.   If your surgeon's office, who deals with the insurance companies all the time, says its so...it probably is.  I bet if you called your insurance company 3 times you would get at least 2 different answers, so I would believe the surgeon first.  It is to their advantage to get you approved so your insurance will pay them for your surgery...they do this all the time, so probably know the answer better than who is answering the phone at the insurance company. I know that some insurance companies limit the number of appeals you can make, so I'm not sure you should risk being denied when you know you probably will not be. Not very helpful, sorry, but I wish you luck!

Angela: Thank you for telling me your story.  Every little bit of information is helpful at this point.   And for reference sake.  I have BCBS PPO out of Michigan. Thanks again, Pam

I have to say that I really learned everything I needed to know on these boards.  Although I'm a nurse, I've never dealt with bariatric surgery before and contreary to what people might think, most nurses don't know much about insurance issues.  The insurance policy doesn't always give you all the information you need to get approved.  I spent a few months prior to even starting on the supervised diet hanging around the boards...taking what information was good and leaving the rest.   Probably would have started the process sooner if not for Katrina, however I started my supervised diet in mid-January and gradually got all my testing done during that time frame and I ended up getting approved just this Monday after submitting to the insurance company on 9/1.   I hope you can get everything in order and not have too much of a headache getting approved!

Angela: Congratulations on your approval! I actually have significant experience with WLS.  Both my sister and mother had great success with their surgeries.  However, neither of them had any type of doctor supervised diet-history requirement dispite the fact that we have the same insurance.   I did some research about 18 months ago when considering surgery and at that time there was no evident of this requirement that I was able to find.  Just that my doctor had to deem it medically necessary and that I passed the medical clearance.  It makes me wonder how long the 12-month criteria has been in place.  But 18 months ago I wasn't ready mentally for WLS because I felt like I needed to give the diet/exercise route one last solid try.  So for the past 13 months I've been on a pretty rigid diet program - approved by my doctor.  But because I didn't know about the 12-month criteria I didn't feel it was necessary to do the monthly appointments... sheesh!  who goes to their doctor when they start a diet anyway?   So now I'm just keeping my fingers crossed and hoping for the best. Thanks again for your help, Pam

I would ask them to submit it anyway, like it is.  My surgeon's office called to get my benefits at my first visit and was told that the DS surgery wasn't covered. However, they didn't use the right code. They didn't want to submit it. I came home investigated myself, found a procedure code and called them back.  For my type of WLS there was no distinction between laparoscopic and open version the duodenal switch surgery. So, they wrote a letter and sent it with the code I provided and TA DA, I'm approved.  Hope this helps a little!! Jinjer

BCBS can be tricky. I have BCBS blue choice POS. They have told me on the phone 3 times. You have to go for a 12 month period but do not have to go every month. The surgeons office says yes it has to be every month. I am sitting kinda in the same boat. If I could go by what the ins. is tell me I could use Nov. 05. But the surgeon office said no...we have to start with April 06.  I should be happy that it is covered and not to many hoops to jump...but I wish left hand and right hand would work together.  5 months difference is a big wait when you are ready now to get this going. I am going for a 2nd opinion with another place that does more surgeries than the place I want to use. Just to see their take on the insurance issue. Becky

Becky: I wish you lots of luck - sounds like we're facing the same situation. And you're right, sure wish the right hand and the left hand would figure out how to work together and know what's going on. Keep me posted on what you find out. Pam

I've heard that 6 month and 12 months diets didn't have to be consectcutive but you did have to have a total of 6 or 12 within the past 2 years (or whatever the plan calls for). I would ask for the specific medical policy that outline the details be faxed to you. Also, if you documented the name of the rep and date and time your spoke to him and what he told you then go with the submission and use that info on the appeal.

I would call BCBS back and ask them if they have anything in writing that specifies the details of WLS approval, including the supervised WL attempt and "frequency of visit" requirements ask them to mail, fax or e-mail it directly to you... and perhaps even ask them to CC your surgeon... but at least get it for yourself.