EmpireBlue BCBS

Does anyone have EmpireBlue from blue cross blue shield?  I have called the insurance a few times to find out the 'requirements' for getting WLS.  No one will give me a straight answer, and i really need to know if there is a required doctor supervised weight loss diet.  I am looking to have surgery in about 4-5 months because that's the best time for my work schedule.  if anyone has any insight, it would be appreciated!!  Thanks

I have it and as far as I have been told, you don't have to do the supervised diet. 

Hi there! I think it depends somewhat on your employer and your state of domicile, but I have Empire BCBS and they require:

-Physician approved documentation of a 6 consecutive month supervised weight management program with a nutritionist or doctor. This 6 months has to be within the last year. They do accept Weigh****chers and Jenny Craig, but you have to be able to show that you went to supervised meetings.

-a letter of medical necessity from your primary care physician.

-psych evaluation from a behavioral health specialist - there is a specific set of criteria that therapist needs to provide ( I can dig up a copy if you need it - let me know)

-be at least 100 lbs overweight or in other words, morbidly obese. That can be a BMI over 40 as well or a BMI of 35+ if you have comorbities such as: diabetes, sleep apnea, heart disease.

Most surgeons offer a program that will help you prepare all of these items and some even provide the nutritionist.  My advice would be to get all the info you can from your surgeon of choice with a good program that has experience dealing with insurance companies. You will also require a lot of pre-op testing. I would anticipate your wait for surgery at about 7-9 months from start of program if you don't already have the documentation necessary to submit for insurance approval. Once your surgeon submits for approval, BCBS has 30 days to respond but I've heard from other insureds that it's much quicker with them if you have all the requirements in order before you submit. Once you are approved, your surgeon will give you a surgery date. Your surgeon may have a wait list, so consider that time as well. The sooner you your first visit with the NUT on the books, the better!

Best of luck - I'm waiting right along with ya!

http://www.empireblue.com/medicalpolicies/policies/mp_pw_a05 3317.htm

You do not have to do a 6 month supervised diet per se, but there must be some diet history.



The patient must have actively participated in non-surgical methods of weight reduction; these efforts must be fully appraised by the physician requesting authorization for surgery; AND



Criteria:

Gastric bypass and gastric restrictive procedures with a Roux-en-Y procedure up to 150 cm, laparoscopic adjustable gastric banding (for example, the Lap-Band^® System or the REALIZE^™ Adjustable Gastric Band), vertical banded gastroplasty, or biliopancreatic bypass with duodenal switch as a single surgery, is considered medically necessary for the treatment of clinically severe obesity for selected adults (18 years and older) who meet ALL the following criteria:

1. BMI of 40 or greater, or BMI of 35 or greater with an obesity-related co-morbid condition including, but not limited to:
   • diabetes mellitus; or
   • cardiovascular disease; or
   • hypertension; or
   • life threatening cardio-pulmonary problems, (e.g., severe sleep apnea, Pickwickian syndrome, obesity related cardiomyopathy); AND
2. The patient must have actively participated in non-surgical methods of weight reduction; these efforts must be fully appraised by the physician requesting authorization for surgery; AND
3. The physician requesting authorization for the surgery must confirm the following:
   • The patient's psychiatric profile is such that the patient is able to understand, tolerate and comply with all phases of care and is committed to long-term follow-up requirements; and
   • The patient's post-operative expectations have been addressed; and
   • The patient has undergone a preoperative medical consultation and is felt to be an acceptable surgical candidate; and
   • The patient has undergone a preoperative mental health assessment and is felt to be an acceptable candidate; and
   • The patient has received a thorough explanation of the risks, benefits, and uncertainties of the procedure; and
   • The patient's treatment plan includes pre- and post-operative dietary evaluations and nutritional counseling; and
   • The patient's treatment plan includes counseling regarding exercise, psychological issues and the availability of supportive resources when needed.