BCBS Wellmark for the DS (lap)... in-network, etc.

Been contacting a lot of surgeons lately, and all of them so far either don't accept BCBS or they're not in network. I'm getting really discouraged.

I'm pulling my surgeon info from the Find a Surgeon & DS Facts lists mainly, and I contact the ones that are in the midwest or east coast who do lap DS.

My insurance company is pretty strict about who they will cover - for one thing, they have to have been doing the DS for a while, and they need to have done a lot of them. It seems most of the guys I have found are primary RNY and have done a few DS, so they are less likely to be acceptable.

Anyway, I need some advice here. I have insurance that supposedly covers WLS. It doesn't say anything about excluding the DS, or only covering the RNY/lapband, so I believe I should be, in theory, ok there.

But how do I find a surgeon that accepts BCBS? Calling them up individually, sending them my info, emailing them back and forth... this is really inefficient and so far fruitless.

The one doctor I really had my heart set on (Dr. Smith) is out of network for me. The coordinator there didn't think BCBS would cover me even though I have no (known) in-network surgeons and so I *have* to go out of network.

Should I just contact my insurance company and ask them if they know any in-network surgeons who do the DS? Would they even know or tell me? Not to be a total cynic, but.. I don't know if they would be helpful since this is an expensive surgery, so I haven't contacted them yet. Should I?

Wait... if they don't specifically state that they exclude DS that does not mean they don't.  They will list the surgery types they WILL pay for, not necessary the types they will not pay for.

First things first, make sure they will cover DS.  Many BC plans consider DS experimental and will not pay for it.  This does not mean  you should not try then appeal, it just means there may be a battle.

Your policy should state clearly which procedures they do cover, it should look something like this (example of one BC policy):

This policy is no longer scheduled for routine literature review and update.

The following criteria and guidelines have been developed to judge eligibility for coverage of bariatric surgery for the treatment of morbid obesity.

To be considered eligible for benefit coverage of bariatric surgery for treatment of morbid obesity, the following two criteria must be met:

1.  A diagnosis of morbid obesity, defined as:

• Body mass index (BMI) of greater than or equal to 40 kg/meter squared; OR
• BMI greater than or equal to 35kg/meters squared with at least two (2) of the following co-morbid conditions which have not responded to maximum medical management and which are generally expected to be reversed or improved by bariatric treatment:
  • Hypertension,
  • Dyslipidemia,
  • Diabetes Mellitus,
  • Coronary heart disease,
  • Sleep apnea.

AND

2.  An appropriate candidate will have evidence that *comprehensive non-surgical treatment has been attempted prior to surgical treatment of morbid obesity

*Comprehensive non-surgical treatment of morbid obesity appropriateness criteria:

• Documentation of active participation in a comprehensive, non-surgical program of weight reduction for at least three (3) months, occurring within the twenty-four (24) months prior to the proposed surgery.  (NOTE: The initial BMI at the beginning of a weight reduction program will be used to meet the BMI criteria for the definition of morbid obesity used in this policy.)
• A program will be considered appropriate if it includes ALL of the following components:
  1. Nutritional therapy, which may include medical nutrition therapy such as a very low calorie diet such as MediFast and OptiFast or a recognized commercial diet-based weight loss program such as Weigh****chers, Jenny Craig, etc.
  2. Behavior modification or behavioral health interventions.
  3. Counseling and instruction on exercise and increased physical activity.
  4. Ongoing support for lifestyle changes to make and maintain appropriate choices that will reduce health risk factors and improve overall health.

Surgical program for the treatment of morbid obesity documentation requirements:

• Documentation that growth is completed.  Generally, growth is considered completed by 18 years of age.
• Evaluation by a licensed professional counselor, psychologist or psychiatrist, must be completed within the 12 months preceding the request for surgery.  This evaluation should document:
  1. The absence of significant psychopathology that would hinder the ability of an individual to understand the procedure and comply with medical/surgical recommendations.
  2. Any psychological co-morbidity that could contribute to weight mismanagement or a diagnosed eating disorder.
  3. Patient’s willingness to comply with preoperative and postoperative treatment plans.

Significant relative contraindications for surgical treatment of obesity include:

• Mental handicaps that render a patient unable to understand the rules of eating and exercise and therefore make them unable to participate effectively in the post-operative treatment program.  An example is a patient with malignant hyperphagia (Prader-Willi syndrome), which combines mental retardation with an uncontrollable desire for food.
• Portal hypertension, which is an excessive hazard when laparoscopic gastric surgery is performed.

GASTRIC RESTRICTIVE PROCEDURES

Gastric bypass using a Roux-en-Y anastomosis (up to and including 150cm) or vertical banded gastroplasty may be eligible for coverage as an open or laparoscopic surgical treatment option for morbid obesity that has not responded to the required conservative measures.

NOTE:  This policy does not address Roux-en-Y gastric bypass performed primarily for the treatment of gastric reflux even though this condition may improve following a Roux-en-Y performed for the treatment of morbid obesity.

Gastric bypass using a Billroth II type of anastomosis, popularized as the mini gastric bypass is considered experimental, investigational and unproven as a treatment of morbid obesity.

Adjustable gastric banding performed laparoscopically or open and consisting of an external adjustable band placed high around the stomach creating a small pouch and a small stoma, may be eligible for coverage as a surgical treatment option for patients with morbid obesity who meet the eligibility criteria for surgery, including lack of response to the required conservative measures listed above.

NOTE:  If the original adjustable gastric banding procedure was a covered benefit, it is not necessary to request documentation for refill and maintenance codes.

Sleeve gastrectomy is considered experimental, investigational and unproven as a treatment for morbid obesity.

MALABSORPTIVE PROCEDURES

The following procedures are considered experimental, investigational and unproven as a treatment of morbid obesity:

• Biliopancreatic bypass (i.e., the Scopinaro procedure),
• Biliopancreatic bypass with duodenal switch, or
• Long limb gastric bypass procedures (i.e. >150cm).

Repeat of a covered bariatric surgery

Repeat of a covered bariatric surgery may be eligible for coverage only when ALL of the following criteria are met:

• For the original procedure, patient met all the screening criteria, including BMI requirements
• The patient has been compliant with a prescribed nutrition and exercise program following the original surgery
• Significant complications or technical failure (i.e., break down of gastric pouch, slippage, breakage or erosion of gastric band, bowel obstruction etc.) of the bariatric surgery has occurred that requires take down or revision of the original procedure that could only be addressed surgically
• Patient is requesting reinstitution of an acceptable bariatric surgical modality.

A Roux-en-Y procedure following vertical banded gastroplasty or laparoscopic adjustable banded gastroplasty is not eligible for coverage for patients who have been substantially noncompliant with a prescribed nutrition and exercise program following the original procedure.

Removal of the gallbladder at the time of an approved gastric bypass surgical procedure

Coverage is allowed for gallbladder removal at the time of a covered gastric bypass surgical procedure, either for documented gallbladder disease or for prophylaxis.

Endoscopic procedures to treat weight gain due to a large gastric stoma or large gastric pouch after bariatric surgery is considered experimental, investigational and unproven including but not limited to sclerotherapy of stoma.

NOTE:  Refer to Medical Policy SUR709.031 named Gastric Electrical Stimulation for coverage when used to treat morbid obesity.
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This particular BC plan does not cover DS.  Your policy should be very clear in what they do cover, not always what they don't cover.

Contact your ins co and ask them what surgery types are covered.  Then ask them for a list of all their in network providers.  That should give you a starting point.
 

 Hmm, maybe they gave me a summarized policy. The one I have is very vague:

Morbid Obesity Treatment
Covered:
Weight reduction surgery provided you meet eligibility criteria for age and medical condition and history. Not all procedures classified as weight reduction surgery are covered. 
Not Covered: Weight reduction programs or supplies (including dietary supplements, foods, equipment, lab testing, examinations, and prescription drugs), whether or not weight reduction is medically appropriate.

Then if I go to their website for more information, the ONLY document it has concerning bariatric surgery is about whether the surgeon qualifies. It has a huge checklist with points to determine if they will cover the particular surgeon. 

Clearly since they said not all procedures qualify, I am going into this assuming that they will deny a DS. But I need to try.

So I will call them Monday and asked for a full policy statement... or ask them for information regarding their covered of weight loss surgery.. not sure exactly what to request, but I'll figure something out. I'll also request a list of their in-network providers too, thanks for the advice, Midwesterngirl =)