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

I dont have the ins that you do, but I got the same replies. I kept calling and calling and left messages. I eventually got transferred to the nurses line where you can ask general questions. From there I wound up with a nurse case manager, the person who will be responsible for wls cases. Once I got her name I kept calling and was able to get a faxed copy of the policy and its requirements. From there I called her back to get clarification on tthe documentations that would be sufficient and to make sure what was meant by the wording. KEEP CALLING. I hope this helps. In the meantime I woudl do everything that the other ladies did even if you dont need it. I am going to submit everything I can get my hand on. Good luck!

I am in N.C and have that insurance. I got the same reponse, so ask them to mail you a copy of their corporate medical policy.  It states the criteria for surgery. I have not been approved as my paperwork is in the surgeons office and I have to meet with him to get approved first. I did not have to have a 6 month diet, however I submitted one to make sure. The insurance person at your surgeons office will help you. I had all my medical records for the past 5 years, they require this and they want to see weights for that time frame as well. The usual medical test and pysch exam, BMI>40 or 35 with co-morbid condition requiring medication prescribed by Dr. must be a medical necessity , so I asked for letters from my sleep Dr and my surgeon that removed gallbladder as well as my pcp.When you call ask to speak to the supervisor when they do not answer your questions, get a name and a reference number for the call. Be assertive in a nice way. I know how you feel, they were not very receptive to me. I kept trying and got the policy sent not once but twice! It is hard to read and make sure you  read the add on provisions! Godd Luck!! Labugmom

I sent this in a message to halfpint, but am reposting for the benefit of all Empire BCBS patients: ***   Saw your message on the insurance boards.  I'm not sure if you've already found the information you need, but just in case you haven't, here's the link to Empire's medical policy on obesity surgery straight from their website.  It even includes a form doctors can submit with their approval request (last page of the PDF).   http://www.empireblue.com/provider/noapplication/f2/s5/t9/pw_ad080419.pdf   If that link doesn't work, go to their website at http://www.empireblue.com.  Click on the left side of the screen that says "Providers and Facilities".  On the right side of that screen should be a box with "Medical Policies".  Click on the "Learn More" button and you'll be taken to a list of all their policies.  This document is called "Surgery for Clinically Severe Obesity." Good luck!