BCBS of NJ Horizon with 60 BMI

Just wondering if anyone has been able to get approval with a 60+ BMI who had Horizon BCBS of NJ?  We have been trying to get an approval for a patient, in the 2nd appeal now.  Just wondering if there has been any sucess with this. Thanks!

I have BC/BS of NJ, the PPO.... was called NJ Plus at the time,  changed in April to NJ Direct.... It took me 2+ years to get approval for a DS, but co-workers with the same insurance got lap bands, and RNY's without trouble.....   (I was a BMI of 74,  friends were definitely 60+ BMI's)   Mary C

Just curious, as I don't know much about it, but is it harder to get insurance approval with a BMI over 60?   My BMI was 48-so not over 60 as you are asking-but I was approved right away (within 4 days) with Horizon of NJ BCBS PPO. 

Hi Amy, BCBS of NJ will not approve Bariatric Surgery for a BMI over 60. Their position on this is that there is no proof that someone with a BMI over 60 will lose enough weight to improve their health and that the risk of surgery is therefore too great.  Kathy

Hi, Kathy I've just been reading all your posts. I am brand new to this, contemplating bariatric surgery with Dr. Nussbaum. I am 5"1, and I weigh 215lbs. You seem to have lost a lot of weight, even though you are petite, like me, and had the lap band rather than one of the more drastic procedures. To what do you attribute your success? Do you have any good advice for me? Like you, I am using Dr. Nussbaum (if Qual-Care approves me, and even if they don't, I will contest it). Also, do you have any suggestions where I can find the best nutritionist to work with me? Debby

Hi Debby, You are in great hands with Dr. Nusbaum....he is fantastic!! You are mistaken however. I did not have a Lap-Band, I had a RNYGB (Roux-En-Y Gastric Bypass). I have QualCare right now and they are pretty good with the approvals. I just had plastic surgery on May 16th. I had a circumferential lower body lift and an inner thigh lift! I'm very pleased with the results and am so happy that i did it. Please feel free to contact me at anytime if you would like any other information. I'd be happy to share. Kathy

Hi, Kathy! Thanks for your reply. You look great by the way. I'm still deciding about which procedure to do. I think I'm going for lap band because I want to get pregnant again at some point, and I've heard it's safer for pregnancy. Who do you use for a nutritionist? I did my consult with someone near me (Monmouth County) and I was not at all impressed with her. I wanted a day by day menu (I'll pay as much as I have to as long as someone is telling me EXACTLY what to eat) but she wouldn't do that.  Who do you use for a nutritionist? Debby

Hi Debby, I don't follow with a nutritionist at this point. I'm also a Bariatric Nurse working for a Bariatric Surgeon so I have the advantage of having a built in dietician in my office should I have any questions (though at 4 years out I pretty much know how to maintain my weight)  If I may give you a quick word of advice..... Keep your options open as to what type of surgery you will have. Speak with Dr. Nusbaum and let him guide you as to what is the appropriate surgery for you. He won't steer you wrong. If you do go with the Band you'll be fine. It takes a little bit of discipline but I know that you can do it.  Kathy

Kathy,  Your post really disturbed me.....  and reminded me why I hate BC/BS so much!   Who needs a drastic method of weight loss more than someone with a BMI over 60????    So far,  I've gone from a BMI in the 70's to a BMI in the 40's...and I'm still losing.  BC/BS has SAVED so much $$$$$$ because my diabetes is well controlled, no more meds.....my hypertension is well controlled,  no more meds, my mobility problems are resolving  etc  etc   etc.   For what it cost them to honor my insurance and pay my surgeon,  they'll probaby make back that money in under two years.....and save on co-morbidities for the next twenty!     I'm a post op bargain to them right now!!!!         Do you have a denial letter or a policy letter about the BMI over 60 stuff.  I'd love to read it! Thanks for letting me rant!   Mary C      

Hi Mary, If you have Horizon all you have to do is call them and request their MOST recent policy on Bariatric Surgery. (it changes frequently!!) They are obligated to either mail it to you or tell you where you can find it online.  Kathy