Question about Horizon BC/BS of NJ....

Hi everyone,

I am new here but I desperately need some answers to give my mind some rest.

2 weeks ago, I went to Barix in Langhorne for a consultation. Everything went great, I am hopefully going to be getting Lap RNY and my surgeon is Dr. Medvetz. Within a week of the consultation, I did everything she told me to do. I got the go ahead from my PCP, I did my psych eval and a sleep study.

Then yesterday I received a letter from Forest Health Insurance Review Specialists that said,

"Based on our past experience with your insurance company (Horizon BC/BS of NJ), we have found that generally there are requirements that you must meet in order for your insurance company to approve surgery. Unfortunately, we cannot submit a prior authorization letter on your behalf until all of your insurance company's requirements have been met.

The following items are what we need in order to submit a pre-determination to your insurance company:

- Medical records

 Documention of successful completion of at least 6 consecutive months within the past year of supervised conservative weight loss program, diet programs/plans (e.g., Weigh****chers, Jenny Craigs), or the Horizon Obesity Disease Management Program.

   Successful completion means formal documentatino or photocopies/print-outs of progress notes of at least monthly follo-up by the supervising physician, other health care prodivder, or program coordinator including the patient's weight and progress relative to the goals set at the start of the program.

I am very upset about this because for over a year I have been dieting. I did Atkins and I did Nutrisystem. I only lost a few pounds on each thing and then it would stall. I could not lose anymore weight. It was not supervised by a doctor because I didn't know I had to do that, but then again I just found out that Horizon BC/BS of NJ would even cover bariatric surgery a month ago.

Also, I found this online, saying it's effective June 19, 2010:

Horizon Blue Cross Blue Shield of New Jersey has recently changed it's position on mandatory participation in a medically supervised weight loss program for six consecutive months prior to Bariatric Surgery.

The revised policy, which becomes effective on June 19, 2010, states the following:

D. Within the 12 months prior to the time of surgery, the member must meet all of the following requirements:  

1. Documentation of previous participation in conservative (non-surgical) weight loss program or diet program/plan (e.g., Weigh****cher, Jenny Craig). [INFORMATIONAL NOTE: Programs supervised by a registered dietitian may not be a covered service under a member's contract.]

Previously, the policy indicated that patients must be enrolled in a medically supervised weight loss program for 6 consecutive months, within the previous 12 months.

Website I found this is here: http://www.njbariatricsurgeons.com/resources/bariatric-news/157-horizon-bcbs-of-new-jersey-changes-weight-loss-surgery-policy.html

Does this mean I don't have to do a 6 month weight loss program that it supervised by a physician? Maybe the Forest place don't realize that the policy has changed because it's been so recent (June 19, 2010)?

Obviously I am going to call them first thing tomorrow morning and tell them what I found, I was just hoping someone could give me some peace of mind. I really don't want to have to do another 6 months of a failed diet before I can (hopefully?!) be approved for this surgery. If that's what I have to do to have this surgery, I will do it. I just had my heart set on having had this surgery and lost weight within the next 6 months. I had no idea I would have to do a supervised 6 month diet, especially since that website says the policy has changed.

Help! :)

Thanks!
Jackie

Hey Jackie,

3 years ago when I went through the process BC/BS of NJ PPO did NOT require a 6 mos supervised program.  However, the tides were changing at that time and MANY insurance companies, were, in fact, beginning to require it right off the bat.

I don't know about the new vs old policies but I would bet $ on the fact that you'll have to do it.  It sounds pretty standard these days.  It sucks, but like you said, if that's what you need to do in order to have the surgery - then that's what you need to do.

Also, be prepared to have more testing done.  Sometimes as your case is reviewed more by the docs at Barix and what not, they decide they need something else....like a cardiac eval or whatever.  Not everyone has this...but just throwing it out there that you might need to.

Hang in there, and welcome to the hardest part of the journey - jumping through insurance hoops!

Pam

Hi Pam,

Thanks for the reply!

I called the insurance coordinator this morning, but I couldn't get in touch with the one who sent me the letter. They more or less said they would know before I did if a policy were changed and one of her patients were denied because she didn't do the 6 month diet. Although, I don't see how she could compare my situation to someone else's, considering there are many different types of Horizon BC/BS, mine is NJ and this person's could have been different.

So I called my insurance company and they said the same thing I read online. No where does it indicate a mandatory medically supervised 6 month weight loss program necessary prior to surgery.

I got a reference # from my insurance company and I'm waiting for the insurance coordinator to call me back about this. I feel like I'm going to have to fight just to prove that's what their policy is. If I have to do the diet, I will, but only once I hear it from my actual insurance company and not this insurance coordinator because that's what they're used to.

I did have an ekg done but I'll be prepared if I need to do more tests.

Thanks!
Jackie

Is the information you have copied here from YOUR policy? 

I work for Aetna and can help you interpret the benefits, but I need to be sure it is YOUR policy and not just random BCBS info.

Hey Jackie, I think we met at the last Tuesday Barix meeting...

Anyway, I just finished the process with Horizon after being firmly denied 3 years ago, complying with all of their needs, and going through appeals. Last fall I was contacted by Barix and after going through Horizon's "six month diet" requirement have been approved. I know it is to document that you have difficulty losing weight under a doctor's supervision but I think it also provides them with a 6 month waiting period and a reason for you to lose interest so they won't have to pay.

The only suggestion I would have is to start now if you have to do it since they will look at months and July is ending soon. Also, as the Barix/Forest rep explained, the Horizon person (and apparently there is one person *****views this diet documentation in NJ) needs to see 7 monthly doctors reports to count the 6 months in between. So it really takes 7 months!

Hopefully you won't have to go through this. Good luck.