Progress Notes BCBS

I have BCBS of NJ.  I have all my paperwork ready to submit for the insurance.  All I need are the progress notes.  What exactly are those.  Are they my medical records from the Dr. who supervised my diet? I have the following: My personal letter Psychologist Letter PCP letter Nutritionist letter Dr. Supervised Diet Letter If there is anyone who has dealt with BCBS - Am I missing anything?  My company J&J covers the surgery through BCBS.  I want to make sure I submit everything that is required to not get denied. Thanks...Cindy

BCBS does not require that you have a supervised diet just that you have been over wieght for more then 3 years. You  have everthing that i submitted and more and i was approved in a week in a half. Good Luck!

First off all BCBS do not have the same requirements. I have BCBSIL, and they required a 6 month Dr. supervised diet. I also had to have medical records proving my BMI was at or above 40 for the past 5 years. Did the insurance company send you a list of their requirements for WLS? If you still have questions about what they are looking for, give them a call.

TO clear this up.... Progress notes are each individual visit note from your diet program.  A doc's summary letter is not sufficient proof of your medically supervised diet. You will be denied if that is all you send as proof of your diet program. They want the actual notes that have your vital signs and documentation from your doc that you talked about your 1200 calorie (or whatever) diet and exercise program. Each monthly note. For all reading this, policies and criteria change from employer to employer, not all BCBS of NJ policies are the same, some employers have different wording in their contract. Congrats on being almost there! Bonnie

The following are the requirement that need to be sent to BCBS of NJ for pre-determination of approval for WLS If NOT specifically excluded by contract, one of the following: adjustable Gastric banding (using the Lap-Band Adjustable Gastric Banding System by BioEnterics Corporation), vertical-banded gastroplasty (using either an open or a laparoscopic approach), gastric bypass with short-limb (i.e., 150 cm or less) Roux-en-Y anastomosis and the biliopancreatic conduit is also 150 cm or less (using either an open or a laparoscopic approach), or biliopancreatic bypass with duodenal switch (using either an open or a laparoscopic approach) is considered medically necessary when all of the following lettered criteria are met: [Please refer to specific benefit coverage for adjustable gastric banding under the Federal Employees Health Benefits Program (FEHBP).] Note: The restrictive component of a standard gastric bypass with Roux-en-Y anastomosis usually consists of a horizontal or vertical partitioning of the stomach to create a small stomach pouch and this is commonly done by stapling. Vertical banded gastroplasty is sometimes performed as a technical variation for this restrictive component.]

A. The member is at least 18 years of age and/or has reached full skeletal growth. Bariatric surgery is considered NOT medically necessary for members under 18 years of age unless the member has already achieved full skeletal growth and has a life threatening co-morbidity (i.e., pseudotumor cerebri, severe sleep apnea, uncontrollable hypertension, incapacitating musculoskeletal disease, etc.).
 
[INFORMATIONAL NOTE: According to published medical literature, bone age can be objectively assessed with radiographs of the hand and wrist.]
B. The member has morbid obesity for at least 5 years. Morbid obesity is defined as either:
1. A body mass index (BMI) greater than 40 kg/m²; or 2. A BMI greater than 35 kg/m² with associated life-threatening or disabling co-morbidities including, but not limited to, coronary heart disease, diabetes, hypertension, or obstructive sleep apnea. Other co-morbid conditions to be considered are: hyperlipidemia, severe GERD, non-alcoholic fatty liver (NASH), osteoarthritis, depression, etc. [INFORMATIONAL NOTE: BMI is calculated by dividing a patient’s weight (in kilograms) by height (in meters) squared.
• To convert pounds to kilograms, multiply pounds by 0.45
• To convert inches to meters, multiply inches by .0254]
C. The member has a BMI that does not exceed 60 (i.e., the member is not super-super obese). Bariatric surgery for members whose BMI exceed 60 is considered investigational since it has not been proven to result in improved health outcomes in this specific subset of individuals.
[INFORMATIONAL NOTE: A number of bariatric studies including The Bariatric Work Group recommendations (Division of Healthcare Quality and Oversight - New Jersey Department of Health and Human Services, October 2005) report higher mortality and morbidity rates in patients with a BMI >60.]
D. There is formal documentation from the treating physician that the member has tried a supervised conservative weight loss program for at least 6 months but has failed to achieve or maintain long-term weight reduction. It should include lifestyle modifications (restricted calorie diet and regular exercise) and behavioral therapy (self-monitoring of food intake, avoidance of triggers to eating, social and family support, cognitive restructuring). Supervised programs may be provided by the patient's physician, a PCP or registered dietitian.
[INFORMATIONAL NOTE: Programs supervised by a registered dietitian may not be a covered service under a member's contract.]
E. The member has undergone a thorough preoperative assessment including psychological evaluation and clearance. ( Please note that psychological testing is NOT included in this requirement.) F. The member has enrolled in a multidisciplinary integrated program to provide guidance on diet, physical activity, and behavioral and social support prior to and after the surgery. [INFORMATIONAL NOTE: It should be noted that all bariatric surgeries require a high degree of patient compliance. For gastric restrictive procedures the weight loss is primarily due to reduced caloric intake, and thus the patient must be committed to eating small meals, reinforced by early satiety. For example, gastric restrictive surgery will not be successful in patients who consume high volumes of calorie rich liquids. In addition, patients must adhere to a balanced diet, including proper micronutrient supplementation, to avoid metabolic complications. (Micronutrients are defined as vitamins, minerals, and trace elements.) The high potential for metabolic complications requires life-long follow-up. Therefore, patient selection is a critical process, often requiring psychiatric evaluation and a multidisciplinary team approach.]

Thanks Vicki....I think (I hope) I have all my bases covered.  I have everything you outlined on your post.  I actually met with the insurance coordinator on Monday and she will submitt everything to the insurance next week.  She has to wait for the transcriptions from my visit with the Surgeon which was also yesterday.  I had seen him before but under a different insurance I had last year.   Cindy

Thanks everyone for your posts.... I have just submitted all my paperwork to the insurance coordinator in my surgeons office.  I am providing them with everything they need and more.  I hope that I get approved quickly.  Others at my job with the same insurance have gotten approval withing 4-5 business days once all required paperwork was submitted. I will keep everyone posted... Cindy