BCBS Alabama question

Hello everyone,

I have just started the long journey toward approval for the lap-band surgery. I met with my primary care physician and she suggested that I use Weigh****chers as my medically supervised diet. She wants to see me in her office once a month to record my weight loss progress or lack of on Weigh****chers. I then contacted BCBS of Alabama to ask them if I could enroll in Weigh****chers Online program as long as I visited my doctor monthly for weigh ins. The customer service person was not helpful and was vague in her answers. She kept quoting the Bariatric Surgery section of the insurance policy. When I pinned her down she said that the guidelines did not state one way or the other if the Online Weigh****chers plan was okay. I then emailed BCBS and they replied that my question had already been answered on the telephone! I am so frustrated with them. My work schedule does not allow me to go to Weigh****chers meetings, so the online plan seems perfect for me if BCBS will accept it. Does anyone have any suggestions for me? Thanks!

Hi!

I have Highmark BCBS of IL.  What exactly does your policy say about your diet?  My policy states I have to do a 6 month medically supervised diet.  That meant I had to go to my physician monthly and get weighed in.  I also had to talk to her about what exercise I had done, what I was eating, etc.  She had to document everything we discussed, if I had lost or gained, any advice on what she thought I could try for the next month.  The whole visit had to be about weight loss. 

I don't think your insurance cares if you enroll in WW, LA Weightloss, etc, as long as your dr. documents your visit with him every month.  I actually joined WW for 6 weeks or so just to help me.  But I didn't keep up with it.  I just kept going to my dr. 

Insurance companies are not very helpful, are they?  Sometimes you run across some very nice people, but I don't think they are aloud to interpret your policy to you... thats why they wouldn't directly answer your question. 

I'm not an expert, but I have been around OH for a year or so.  I have read a lot.  Without seeing what your policy states, its hard to be sure.  Just make sure if you go to your dr each month, he is very wordy about your visit! 

Good luck!!!

Hello.  In the guidelines to having gastric bypass, they tell you in the rules that if you are not located near a weigh****chers and can not go to a meeting that it does not count.  My suggestion to you is to go ahead and look for a surgeon, and make an appointment.  Usually they make you go to an orientation and during that time they will go over insurance requirements.  I have BCBS of alabama, and as long as you are covered for wls, they will pay for you to go for the consultation.  I would be really careful about the online weigh****chers, I would not think that they would cover that as a supervised diet.

I too have BSBS AL and am in the midst of appealing their denial of my WLS...and they now DO NOT pay for the consultation! New rules they have started... now my surgeon says that if they get the WLS approved, they go back and resubmit the consult and BCBSAL will pay it then...but they will NOT pay it up front now. My surgeon has someone that is working on putting some kind of legal action to BCBSAL about this as our plan clearly states that doctor office visits are covered... But I confirmed it with BCBSAL and they refused to pay for the consult before WLS! Surgeon said Atena is also starting to follow this practice! Said it was one more way that ins. companies are trying to screw their way outta paying for services!! AND...now ins. companies are refusing to cover your visits after WLS...when you are no longer morbidly obese they claim you should not be seeing a surgeon!  My surgeon's office is now learning to code their office visits as falling under "mal absorption" and it s being covered for now until ins. companies can figure out another way around paying! I hate INS companies but I have to deal with them and use them... Cheers, Tee

I have BCBS of AZ- so my policy might be different from yours- BUT my policy clearly states "- A structured program that includes documentation of diet and dates of participation (a minimum of one face-to-face visit per week attendance for dietary counseling/education is required) " Again, my insurance could be different from yours- but it sounds like it is pretty similar. Go onto your bluecares website and get the information.

I would first of all call BCBS back, and if they don't answer your question clearly, ask to speak with a supervisor.  I am in the process of starting my 6 month supervised diet as well.  I was researching today what BCBS of AL requires for the Lap- Band Surgery on their website, and found the following link to Q&A's for bariatric surgeons which is listed on the policy for surgical management of obesity. http://www.bcbsal.org/providers/pdfs/Q&ABariatricNetworkFinal.pdf These items seem to somewhat cover your question.  I do wonder, however if you can do the online WW, and then check in with your doctor for the documentation.

 

9. What does Blue Cross and Blue Shield of Alabama consider a medically

 

supervised diet?

 

A physician-supervised program consists of nutrition and increased physical activity (including

 

dietitian consultation, low calorie diet, increased activity and behavioral modification). There must be documentation in the medical record of program participation by the attending physician of that organized program or the patient’s primary care physician. Documentation should include patient progress or lack of progress.

 

OR

 

A person may participate in programs such as Weigh****chers, LA Weight Loss, Eat Right, etc.

 

There must be medical supervision that includes visits to the patient’s primary care physician,

 

documentation in the medical record that the patient is attending a program and the status of the weight loss attempt.

 

Letters do not meet the documentation requirement for either method used as a weight

 

loss program. Medical records must be submitted along with the program records from the patient.

 

10. a. In some areas of Alabama, there is not a medically supervised weight loss

 

program available and many are unable to afford to attend what is available.

 

Is it appropriate to see a physician and be placed on a diet?

 

Documentation must be present of participation in a physician-supervised program of nutrition

 

and increased physical activity (including dietitian consultation, low calorie diet, increased

 

physical activity and behavioral modification). Documentation of program participation must

 

appear in the medical record by the attending physician. Documentation should include

 

comments by the physician regarding patient progress or lack of progress. A letter does not

 

meet this requirement. There must be medical records to document medically supervised weight loss attempts.

b. What if a person works out of town during the week and is unable to attend a

 

weight loss program?

 

If the person is unable to attend a medically supervised weight loss program, they are not able to meet Blue Cross and Blue Shield of Alabama’s criteria for coverage of bariatric surgery.

 

12. When does the six-month weight loss attempt begin?

 

At least one attempt of a medically supervised diet must be documented for at least six consecutive months in the one year prior to the request (predetermination) or date of surgery if no predetermination is requested.

 

13. For purposes of Blue Cross and Blue Shield of Alabama coverage, what physicians can medically supervise the dietary attempts to lose weight?

 

Family practitioners, internal medicine, and other primary care specialties such as OB/GYN can medically supervise a patient’s dietary attempts to lose weight. Dieticians employed by or acting as consultants to the bariatric surgery practice do not satisfy the requirements for pre-operative dietary attempts at weight loss.

 

 

17. How frequently should visits be made to the physician supervising the weight

 

loss attempt?

 

Monthly physician visits, or three physician visits during a six-month nutritionist-led intervention, would be sufficient for coverage purposes.

 

Examples:

 

If a patient’s weight loss attempt is being monitored by the primary care physician there should be no less than monthly visits with documentation for six consecutive months.

 

If a patient’s weight loss attempt is nutritionist-led, such as Weigh****chers, three physician visits during a six-month interval are sufficient along with the documentation from the Weigh****chers’ weekly visits.

 

If the patient is seeing a dietician (not associated with the bariatric surgery practice) for supervision of weight loss attempts, three physician visits during a six-month interval are sufficient along with the documentation from the monthly dietician visits.

18. Does the weight loss program have to be the same for the whole six months or can the patient try different programs for six consecutive months?

 

The patient is required to be in any approved program for six consecutive months.

 

19. If a patient presents with a documented three-year history of morbid obesity, undergoes the six consecutive months of weight loss program under the supervision of their primary care physician, and actually loses enough weight to be below a BMI of 40 or 35  with co-morbid factors, does this meet the criteria for bariatric surgery?

 

A BMI of less than 40 or 35 with co-morbid factors does not meet the criteria for coverage of

 

bariatric surgery. These patients should be encouraged to continue with their successful weight

 

loss program.

 

20. If a patient met the criteria for BMI requirements five years ago, has lost weight and now the patient is morbidly obese again with recent weight gain, is the review from fiveyears or do we adhere to the three-year morbid obesity requirement?

 

The condition of morbid obesity (BMI ≥ 40 or BMI ≥ 35 with co-morbid conditions) must be of at least three years duration prior to being considered for coverage. The three years is considered on the basis of consecutive time at levels of morbid obesity, not total time over extended periods. Any time a patient’s BMI falls below the criteria threshold is considered a break in consecutive months. If in the future a patient’s BMI again reaches threshold, a new three-year period will begin.