BCBS of North Carolina

Okay Gals and Guys.. I am in the process of trying to get Blue Cross/Blue Shield of North Carolina ..Well that part is pretty much set ... I just gotta pay my first premium and it starts a couple of weeks later .. It is actually Blue Advantage.. I made an anonymous call to an agent and asked about the gastric bypass surgery... and they said that they would not cover it unless it is absolutely medically necessary ... okay that doesn't surprise me but .. the agent was saying that a letter of recommenation from my primary physician would not be sufficient.. I have to prove my case ... What does that mean ??? She had a horrible attitude ! What is the beginning process? Will someone tell me ..

Have you tried looking at the medical policy on line?  You could google it look for the blue advantage medical policy. 

What surgery do you want to have?  I know that most bcbs cover the RNY and lap band.  I have federal bcbs and they covered my lap band back in 08. 

This year I had a revision surgery from the lap band to the vsg.  So far FEDERAL BCBS paid only part of my VSG surgery.  I'm in the process of appealing.  

 If you know what surgery you want check on that particular forum and some folks will chime in and answer your questions i'm sure.

I had the VSG and absolutely LOVE IT............ 

blessings to you
babygirlinokc

 

Thanks for responding .. I was looking into DS, or the VSG.. I like that the VSG .. doesn't move your intestines... but I worry about about after your tummy stretches out.. (I know it won't stretch but so far).. but still ... this policy is actually the blue advantage of North Carolina.. .

Different companies require different things.  You'd need to get their criteria from them.  Get it in writing.  Usually they do require more than just a letter from your PCP.

Normally you must have a BMI of 40 or more.  35 or more if you have comorbidities like diabetes or sleep apnea.

You usually have to have a history of obesity.  Like, medical records going back for several years showing your BMI has been over 40 for some length of time.  With some insurance companies, it's just two years.  With many, it's five years.

Often, you must show that you've attempted to lose weight by dieting and it hasn't worked.  They may also want you to have tried an exercise program, and maybe prescription diet medications.

Kelly

Thanks for responding... my bmi is pretty high ..around the 60's and I have high blood pressure .. I can see how the insurance process can prove to be a bit frustrating.. ..

Thanks for responding... and thanks for the information.. this process.. (which I still haven't decided on) is gonna be ..

I have BCBS of NC through my state health plan. The process was pretty simple really. You need to read your policy to see what their version of medical necessity is. For me, it had to be a BMI of 40 or more or 35 or more with co-morbidities. This could be anything from diabetes, sleep apnea, edema, insulin resistant to more serious health problems.
I didn't have to have a letter from my PCP but this would be fairly easy to get. I set up an appointment with the surgeon of my choice, went through the seminar, the testing and then he submitted it to insurance for approval. Most BCBS will cover RNY and lapband with no problems.
Proving your case simply means meeting the surgeon's criteria.

Thanks for responding.. and oooohh.. I like how simple your process was ... I meeting more folks with the VSG.. and they are loving it .. (like I said before) I like the fact that the intestines are not moved.. ..(hmm)..