Question:
Has anyone been approved who has BC/BS of Pennsylvania?

If so, what was their requirements?    — tanyad50 (posted on April 30, 2008)

April 30, 2008
I had BCBS of Florida and all WLS are plan exclusions. I was a self pay. Check your Plan booklet under exclusions, call the 1-800# and ask what their policy is and check it out thoroughly so you can be well informed. Good luck, Dawn Vickers, RN, BLC, CLC
   — DawnVic

April 30, 2008
Are you part of Highmark BC/BS? If so: Patient Selection Criteria "The patient is morbidly obese; Morbid obesity is defined as a condition of consistent and uncontrollable weight gain that is characterized by a weight which is at least 100 lbs. or 100% over ideal weight or a BMI of at least 40 (V85.4) or a BMI of 35 (V85.35-V85.39) with comorbidities (e.g., hypertension, cardiovascular heart disease, dyslipidemia, diabetes mellitus type II, sleep apnea). The patient is at least 18 years old; and The patient has received non-surgical treatment (e.g., dietitian/nutritionist consultation, low calorie diet, exercise program, and behavior modification) and attempts at weight loss have failed. The patient must participate in and meet the criteria of a structured nutrition and exercise program. This includes dietitian/nutritionist consultation, low calorie diet, increased physical activity, behavioral modification, and/or pharmacologic therapy, documented in the medical record. This structured nutrition and exercise program must meet all of the following criteria: The nutrition and exercise program must be supervised and monitored by a physician working in cooperation with dieticians and/or nutritionists; and The nutrition and exercise program(s) must be for a cumulative total of 6 months or longer in duration; and The nutritional and exercise program must occur within two years prior to the surgery; and The patient's participation in a structured nutrition and exercise program must be documented in the medical record by an attending physician who supervised the patient's progress. A physician's summary letter is not sufficient documentation. Documentation should include medical records of the physician's on-going assessments of the patient's progress throughout the course of the nutrition and exercise program. For patients who participate in a structured nutrition and exercise program, medical records documenting the patient's participation and progress must be available for review. The patient must complete a psychological evaluation performed by a licensed mental health care professional and be recommended for bariatric surgery. The patient's medical record documentation should indicate that all psychosocial issues have been identified and addressed. Patient selection is a critical process requiring psychiatric evaluation and a multidisciplinary team approach. The member's understanding of the procedure, and ability to participate and comply with life-long follow-up and the life-style changes (e.g., changes in dietary habits, and beginning an exercise program) are necessary to the success of the procedure. If the patient does not meet all of the patient selection criteria for bariatric surgery, the procedure will be denied as not medically necessary. A participating, preferred, or network provider cannot bill the member for the denied services."
   — nursenut

April 30, 2008
I had Highmark BC/BS and besides being 374 lbs....isn't that enough criteria, lol, all I had was borderline high blood pressure and asthma which was just diagnosed the year before, so it was pretty easy for me. They required the 6 month weight study with the doctor but my doctor pretty much waived that and used the prior visits I had made and went off that, he thought that the insur. companies required too much of people to have the surgery. I had the psych eval and that was pretty much it. There was no weight requirement or had to have so many ailments, no I went in told my doctor I wanted to have it done and he was on board with me. I met up with the surgeon and had all of the blood work and x rays needed and was scheduled for surgery. Hope this helped and good luck.
   — PAWLLA L.

April 30, 2008
I live in PA, I have BC/BS I think it is called "access care II", I have no idea,,,but yes, I was approved to have the surgery AFTER meeting ALL of their criteria, & I had my surger on April 17th of this month. I am recovering well, however, I did not receive any bills yet. I know there is a $2,000 co-payment as per my particular plan, but I'm not sure about the co-insurance, or if there even is one, I think the $2,000 is it, but who knows with insurance companies these days,,,,let me tell you how to view the "criteria" on line on their website,,go to www.bcnepa.com,,,,along the top are the headings, VISITORS, MEMBERS, GROUP ADMIN, PROVIDERS,,,,click on PROVIDERS,,,then go to medical policies,,& find the one for morbid obesity & there you have all of their ridiculous criteria that you must meet, I also had to join a 6 month program at Lehigh Valley Hospital (to the tune of $400) in order to have the surgery there by my chosen surgeon (Dr Peter Rovito in Allentown-EXCELLENT) I would only recommend surgery if you were to go to him,,,hes fabulous! Anyway, I didn't find it too hard to prove those things,,,,hell, 2 of the 3, 6 month long diets I was on, were when I was an adolescent/teenager. The most recent one being at Lehigh Valley Hospital. If your family doctor is not against WLS in general, you should be fine! if you need any help,please let me know!!!!! oh, yes, I don't know if you are a smoker, but I had to quit & THEY DO test you prior to approving your surgery!! Denise
   — [Deactivated Member]

May 1, 2008
Hi, I have BC/BS of PA, actually Personal choice. My surgery was approved in about 15 days even before I had any pre-surgery tests. I have diabetes and other co morbidities, but their criteria are age up to 65, 100 pbs overweight, comorbidities etc.
   — SkinnyLynni2B

May 1, 2008
Hello, I have Personal Choice (part of BC/BS of PA) and my surgery was approved within a week of submitting to the insurance co and I had no co-morbidities, just a bmi of 41 and 100+ excess weight. I had the surgery in Dec '07 and the only deductible I had to pay by my plan was $75/day for the hospital and I was only in 2 days for the RNY lap. I also did not have to do the 6 months diet supervision. So my entire pre-op and then approval processes went extremely quick. Good Luck!
   — jenndolyn