Question:
Blue Cross Blue Shield Of Alabama 3 year obesity criterria?

I am 38 years old. I have a BMI of 40.7 @ 5'2 and hypertension,arthritis,acid reflux,depression and restless leg syndrome. I have done the 6 month diet program and been Denied Twice because of lack of 3 year obesity. I have been 100 lbs.overweight for a year. I weigh approximately 224. HELP ME!!    — kimberly-07 (posted on April 11, 2007)

April 11, 2007
HI Kimberly, The only advice I can think of is to obtain your medical records from your PCP, hopefully they have weighed you in when you were seen and if it shows a pattern of being obese.. (and being obese is not necessarily 100 pounds overweight.. check the BMI charts..) then you should be able to use that as proof. Check your weights in the BMI chart to show if you were truly "obese" throughout those 3 years. Good luck!! April
   — April

April 11, 2007
Every insurance plan has their own guidelines for the surgery. If they are saying you must be obese (40+ BMI) for 3 years then there probably isn't any way around that. Can you change insurance companies during your annual enrollment period? That is what several people I worked with did when they wanted the surgery because Cigna and United Health Care was approving it was ease but Blue Cross wasn't at the time. If you can do that, then I would check with the other insurance companies that are offered and see what their guidelines are, if you can't then basically you are SOL unless there is any other clause in the policy that allows it. I would get a copy of your insurance policy which discusses weight loss in detail - you may need to call your insurance carrier and ask them for a copy of the ENTIRE WEIGHT LOSS SURGERY POLICY so you know what they do and do not allow.
   — JGDugar

April 11, 2007

   — Kari_K

April 11, 2007
If your physicians are writing this surgery up as a medical necessity then they should not be turning you down. Sometime BCBS can be such a pain in the but. Also you can check the State of Alabama's Department of Health definition of Morbid Obesity and see if the state has mandated any legislation that the insurance be covered. If you take the BC off their title you'll see they are just BS.
   — the7thdean

April 12, 2007
Hello Kimberlie, thanks for writing. You can't get around what insurance requires. There is a reason why they ask for a history to go back 3 years. I know you are miserable, but if you have been at this weight for a year, then the only thing you can do is look at other health issues. If you don't have enough of other health issues to apply for an appeal of their decision, then just be patient and wait it out. That really is your only choice. Keep in mind that depression can cause you to NOT have surgery, so keep that in check, and if your PCM will support that they would like you to have it now, they can write a letter of appeal. In the meantime do things that will move you forward in your health. An appeal is your only option besides waiting. Take Care, Patricia P.
   — Patricia P

June 6, 2007
I also had to show medical weights for three years of obesity to qualify through Al. BCBS, but-I was told that if you can provide dated pictures and your physician is willing to write a statement that based on the pictures he can surmise that you appear to be obese or 100 lbs. overweight, then that will also be accepted. You may want to go back and try to find some and even think about asking friends and relatives for holiday, outings, or family pictures over a certain time frame. Most are dated on the back. Your doctor will probably be willing to observe and make a guestimated statement based on your appearance in the photos. It is worth a try. Best of luck!!! Lisa
   — Lisa T.