Horizon NJ/BCBS PPO

Has anyone been "approved" or "denied" by them recently for the "6 month medically supervised diet"??? I was just told that they needed this information and I've asked them several times over the last few months and I was told that I only needed the "Letter of Necessity" (which they never told me what that entailed)!! I AM SOOOOO FRUSTRATED!!! And my surgery is scheduled for November 9th!!

get your primary doctor to write a letter of medical necessity stating your weight history and what you have done and not succeeded at over the past few years. that should do the trick. be sure they mention any co-morbidities that you have, i.e. hypter tension, sleep apnea, etc. and have them state that your health requires you to have this surgery now. good luck, jacki

Jacki: My letter states all those things.. I also had a sleep study done which resulted in me having a "mild" form of sleep apnea! I submitted the results from that test as well!! Thanks

It doesn't matter what others have experienced. What matters is what *your* insurance policy requires. Two people can have bcbs and the terms of one ppo policy can vary quite a bit from the ppo policy of another. All depends on what was written in the policy and what the employer (if it's a group policy, for example) is willing to pay for.

Hi Eileen, I think I finally have the answer to the BCBS PPO question. After I went thru the psyc eval and nutrition and a endiscope o also saw heart dr for medical clearance and bloodwork pre admission consult with anistesiologist and registering for surgery at hospital today for surgery THIS MONDAY..... BCBS said that they want a 6 month diet and exercise program.Also told surgeon that this is a new requirement as of Jan I dont get it??? Anyway all the anxiety about the surgery and prep amounts to nothing but disappointment. I just dont know..

I know people get all wild when their insurance companies demand a six month supervised medical diet. I had Horizon NJ/BC/BS PPO also, and I had a well doucmented histrory of weightloss efforts that were supervised by my Primary care doc and the several dietitans he sent me to over a 5 year period. As a matter of fact, my primary swore he would never sign off on WLS, but finally relented after all of my dedication to regimens he prescribed failed to produce lasting weight-loss. The long and short of it is that I had the documentation that I needed for my approval...But I still waited 7 months for an approval because my surgeon required many, many pre-surgical consults and every time their was an abornormality, I had to resolve it before the consultant would sign off. There is some value in this six month diet requirement. 1st and foremost, even a modest weightloss will lessen the chances of surgical complications...One of the unspoken secrets of WLS is that fat doesn't heal very well. Abdominal fat has very little blood circulation and does not heal very well...Many of us have wound healing issues...The less abdominal fat with have the better we will heal. Secondly, it prevents people from making a rash decision; if you have to comit to a six month weight-loss program, they know you are not just jumping into the deep end....this prpbably doesn't apply to you, but many people do not properly research this procedure and do it without concerns for complication rate or a true realization of how much this surgery impacts on every aspect of your life. I truly sympathize with your frustration, though...You have prepared yourself emotionally to do this surgery now....My real frustration with the isurance company would be...Why the runaround...If this is the policy they sure as hell should tell you up front...If you are preparing for this life changing event...you deserved to be made aware of the policies and procedures in advance, anything less is just not fair. The good news is that they are still approving the procedure...many of the Blues are putting exclusions in their policies against this procedure....An unfair policy to say the least.... Good luck and I am sorry for your frustration.... Kelly

Kelly: Thanks for getting back to me... my insurance woe's was the topic at my surgeon's support group meeting last nite! Even the RN and the Dietician that were there know about all the crap w/ BCBS/Horizon NJ! They and the surgeon's are just as pissed/frustrated as us patients! I was told to keep my head high and fight it! I am emotionally/mentally and physically prepared for this surgery. I've done soooo much research on WLS it's not funny! And everyone that knows me my friends at home and at work know I'm am ready for this! I have a lot of support behind and just want to be on the "loser" side already! Thanks once again!

I was just approved yesterday. I started my journey in August and I am surprised that I have been approved so fast. My date is set for Nov. 2. I recieved a letter in the mail on Oct. 16 stating they needed the same material, I called and they said my Surgeon had taken care of that already. Then on Wed. I got the call from Dr. Fares office stating the insurance approved me. I hope the best for you and I am sure they will get it all together. Stay positive and keep your chin up.

Thanks Moniquea: I'm trying, I really am!!! Good luck w/ your surgery.. and I def think you should wear the nose! Best of Luck!